March 2021 Volume LVI Number 2

 
 
 
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Resident's Corner

January 2021 Volume LVI Number 1

Treating the Medically Complex Child
 
Looking at tomorrow’s schedule, you see you have Eric, an 11-year-old patient here for a recall. Curiously, you click on his Dentrix chart and see that he has Downs Syndrome, intellectual disability, hypothyroidism, asthma, an atrial septal defect and obstructive sleep apnea.
 
What is your plan for tomorrow and how will you modify your care? Treating medically complex children can be intimidating. It does require some additional preparation and planning on the end of the provider. Luckily, there are some strategies that can simplify the process.
 
One strategy is to make a "Patient List" the day before the appointment, detail- ing the patient’s medical history that was noted in the previous appointments. Completing this exercise allows the provider to become familiar about the patient’s medical conditions and how they may affect the care provided. Additionally, it helps to anticipate some more refined questions you would discuss in your medical history review with the patient’s caregiver.
 
As a dental provider, it is paramount to understand the patient’s complete medical background. One resource specific to pediatric dentistry is the Pediatric Dental Study Guide website (pediatric- dentalstudyguide.weebly.com) which succinctly provides the background of various medical conditions, their dental manifestations, and implications on dental care. Although it is geared towards general dentists, Little and Falace’s "Dental Management of the Medically Compromised Patient" also provides a good background on the physiology
and pathophysiology of various medical conditions.
 
The day of the appointment, one question that can be a helpful lead is "Which Specialists does the patient see?". Generally, the first comprehensive exam appointment may function as an information gathering appointment. You may need to send out consulta- tions to medical partners to fill in any holes or uncertainties in your patient’s history. In complex cases, it is prefer- able to pause before proceeding with rendering treatment with uncertainty. Some information you can gather from consults are if there are any contrain- dications to care in a traditional dental clinic setting, whether the patient can be reclined completely, if the patient needs antibiotic prophylaxis or if there are con- traindications to passive restraint, local anesthetic and/or epinephrine. Gener- ally, consultations should not request permission to provide dental treatment; rather, they should be gathering clarifi- cations or details to better inform your choices on how to provide care for your patient.
 
If you work with medically complex patients, you need to be prepared to re- spond in case of a medical emergency. It is important to be able to recognize the limitations in a traditional dental clinic setting. In some instances, it may be better to defer care to a hospital-setting. Likewise, once a patient reaches a certain age, helping them transition to a general dentist who is comfortable with special health care needs is important for the patient’s dental health.
 
You decide to do a recall exam for Eric. He is taking Flovent, Synthroid, Zyrtec and Monteleukast daily and his Albuterol inhaler as needed. He has no allergies. Eric has seen ENT, endocrinology, and cardiology specialists in the last six months. During your exam, you see a class III skeletal profile and calculus consistent with his diagnosis of Downs Syndrome. You also note small caries on #19B. Due to his intellectual delay, you decide to utilize a Large Joey Board and the Molt Prop for Protective stabilization. Your assistant can take radiographs with mom’s help with the Nomad. Since Eric has an atrial septal defect, you decide not to complete the prophy and scal- ing but instead send his cardiologist a consult regarding antibiotic prophylaxis. Mom will have him schedule another ap- pointment to complete his prophylaxis and silver diamine fluoride application on #19.
 
Working with a medically complex patient is a challenging but rewarding experience. There is a large barrier to ac- cess to care for this population and those who are able to understand the needs of these children are chipping away at these care gaps. It may require additional attention to detail, but it is extremely gratifying.
 
Naheed Ahmad, D.M.D, is a first-year pediatric dental resident at NYU Langone – San Diego. She grew up in Chicago and com- pleted her B.S. in Biological Sciences and her B.A. in Psychology at the University of Illinois in 2013. She also completed her dental pre-doctoral education from the University of Illinois in 2017. Prior to residency, she worked for three years as a General Dentist with National Health Service Corp Scholar Program in a Federally Qualified Health Center in southern Wisconsin.

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