15.4 Special Needs Patient Management: Older Adults, Pregnancy & Medical, Physical or Cognitive Conditions

15.4 Special Needs Patient Management: Older Adults, Pregnancy & Medical, Physical or Cognitive Conditions

Quick Answer: Competency 5.4 asks the assistant to help manage patients with special needs. These include children, older adults, pregnant patients, and people who are medically, mentally or physically compromised. The aim is safe, respectful care that is adjusted to the person, not withheld. Key tasks are:

• review the health history and alerts before seating the patient;
• book appointments at the best time of day for that person;
• speak to the patient first, even when a caregiver is present;
• confirm who can give consent;
• adapt the chair position and the length of the visit;
• adapt oral hygiene aids, for example a modified toothbrush handle for someone with limited grip.

1. General Principles

• Plan ahead. Before the visit, ask about mobility aids, communication needs, medications, the best time of day and whether a caregiver will attend. Flag these in the record so the whole team knows.
• Respect autonomy. Address the patient directly, at eye level, and ask how they prefer to be helped. Never talk over the person to the caregiver.
• Consent and capacity. An adult is presumed capable unless shown otherwise. If the patient lacks capacity for a decision, consent comes from the legally authorized substitute decision-maker under provincial law (section 2.3). Record who gave consent.
• Short, well-organized visits. Prepare all instruments and materials before the patient is seated. Schedule extra time for transfers and communication.
• Safety. Know the emergency plan (section 16.3). Keep the patient's own medications nearby (for example, inhalers, nitroglycerin, glucose).

2. Children (Pediatric Patients)

• Use tell-show-do, positive reinforcement and age-appropriate words (section 15.2).
• Morning appointments often work best for young children, when they are rested.
• A parent or guardian gives consent for a young child (the rules on mature minors vary by province).
• Watch for signs of abuse or neglect and report concerns as required by law (section 2.4).

3. Older Adults (Geriatric Patients)

• Positioning: older adults may be unable to recline fully because of back pain, breathing problems or reflux. Raise the chair slowly and let the patient sit for a moment before standing to avoid postural (orthostatic) hypotension.

4. Pregnant Patients

• The second trimester is generally the most comfortable time for routine elective care. Necessary treatment, including emergency care, can be provided in any trimester after consulting the dentist (and the patient's physician when needed).
• In the third trimester, avoid lying flat. Tilt the patient to the left side (a wedge under the right hip) to prevent supine hypotensive syndrome (section 9.1).
• Radiographs that are needed for diagnosis may be taken with normal protective measures (section 8.1).
• Pregnancy gingivitis and pyogenic granuloma are common (section 4.2). Reinforce oral hygiene. Vomiting from morning sickness exposes teeth to acid: advise rinsing with water (or a baking soda solution) and waiting before brushing.
• Medications are chosen by the dentist. Many local anesthetics, including lidocaine with epinephrine, are commonly used. Acetaminophen is usually preferred to NSAIDs for pain relief.

5. Medically Compromised Patients

6. Patients with Physical Disabilities

Wheelchair transfer

1. Ask the patient whether they wish to transfer or be treated in their own wheelchair (some wheelchairs tilt, or a wheelchair platform may be available).
2. Move the dental chair arm out of the way and lower the chair to the height of the wheelchair seat.
3. Position the wheelchair beside the dental chair, lock the brakes, and remove or swing away the footrests and the armrest on the transfer side.
4. Use a one-person or two-person transfer (or a transfer board) as the patient directs. Bend at the knees and keep your back straight to protect yourself.
5. Secure the patient's legs and position them comfortably; store the wheelchair close by.
6. Reverse the steps at the end of the appointment.

• Mobility aids (walkers, canes) stay within the patient's reach. Service animals are allowed to accompany the patient.
• Spinal cord injury: watch for autonomic dysreflexia (a sudden, severe rise in blood pressure, headache and flushing). Stop treatment, sit the patient up, check for a full bladder or tight clothing, and call for help.
• Cerebral palsy and movement disorders: a calm environment, a mouth prop if the dentist approves, and gentle support of the head.

7. Patients with Mental, Intellectual or Sensory Disabilities

• Intellectual disability or autism spectrum disorder:
  • visit the office first so the patient can get used to it
  • use a consistent team and room
  • plan for reduced noise and light
  • use simple words, pictures or a visual schedule
  • give praise
  • let the caregiver help explain.
• Mental health conditions: some medications cause xerostomia or interact with vasoconstrictors. Anxiety may need extra time and clear explanations.
• Visual impairment: introduce yourself, describe what you are about to do, guide the patient by offering your arm, and do not move items they have placed.
• Hearing impairment: face the patient, use written notes or sign language interpreters, and ask whether the patient prefers to turn down or remove a hearing aid during ultrasonic or high-speed handpiece use, because it may whistle.

8. Adapting Oral Hygiene Aids

• Modified toothbrush handle: enlarge the handle with a foam tube, a tennis ball, bicycle handgrip or custom acrylic. This helps patients with arthritis, limited grip or tremor. An elastic strap or a bent handle can help those who cannot close their hand or raise their arm.
• Powered toothbrushes, floss holders and interdental brushes with long handles.
• Caregiver brushing: teach caregivers to stand behind the seated patient, support the head, use a mouth prop or a second toothbrush to retract, and use a small smear of fluoride toothpaste for people who cannot spit.