The Japanese Society for Disability and Oral Health (JSDH) established the qualifications of JSDH authorized instructor for certified dental hygienists (instructor DH) and the Japan Dental Hygienists’ Association authorized dental hygienists (Accreditation B : Disability dentistry) (certified DH) in 2008. The guideline for certified dental hygienists recommends that DH instructors must train certified DH according to the guideline. However, there are no reports that examined the achievement status of the items presented in this guideline in dental training or guidance for DH.
Therefore, the purpose of this study was to understand the achievement status of DH guideline items involved in dentistry for patients with disabilities by conducting a questionnaire survey according to the training guidelines.
The survey was conducted on instructor DH, certified DH, and uncertified general DH. The survey examined the characteristics of the achievement status of each training guideline item of instructor DH, certified DH, and general DH. It was suggested that not only clinical experience but also differences in historical background and curriculum were involved in some of the training guideline items.
Based on these results, it is necessary to investigate the achievement status of each training guideline item in DH training in order to examine the items required for DH education in future. It is also considered that this could be used when considering adding training items.
In order to clarify the bacterial flora of elderly people with tube feeding and the factors affecting the bacterial flora, the bacterial flora in the palate, tongue, and pharynx of tube-fed people and people with oral intake were analyzed by next-generation sequencing analysis (NGS). Factors affecting the bacterial flora were examined using principal component analysis and correlation ratios. The subjects were 20 elderly people with tube feeding and 19 elderly people with oral intake. The age, gender, disease, and bedridden level were confirmed from the hospitalization records. The Japan Coma Scale, consciousness level, communication status, presence of remaining teeth, and CPI were evaluated by a dentist. Sampling was performed on the palate, tongue, and pharynx by the swab method. Next-generation sequencing was performed according to the conventional method, and the types and composition of bacteria were also evaluated. The Shannon index of the tube group in the palate, tongue, and pharynx were significantly lower than those of the oral intake group. The tube group had significantly more aerobic bacteria in the palate, tongue, and pharynx than the oral intake group. The facultative anaerobes of the tongue and pharynx in the tube group were significantly higher than those in the oral intake group. The bacterial composition of the palate, tongue, and pharynx in the tube group was predominantly the same : Neisseria, Streptococcus, and Rothia. Principal component analysis between the two groups showed that the contribution of the first principal component of the palate was 21.3%, 32.7% for the tongue, and 30.1% for the pharynx. In the palate, tongue, and pharynx, the correlation ratio of “tube/oral intake” was the highest. The correlation ratio of “tube/oral intake” in the palate was 0.423, the tongue was 0.517, and the pharynx was 0.518. The factor most closely associated with the palate, tongue, and pharynx flora was “tube/oral intake”. The flora of the palate, tongue, and pharynx in the tube feeding group had more predominantly aerobic bacteria and was low in diversity.
Oral hygiene management from a young age is important, but children who started management from a young age do not necessarily grow up without developing dental caries. In this study, we investigated the relationship between the incidence of dental caries during the management period and factors related to oral hygiene habits, developmental age, and characteristics of autistic spectrum disorder (ASD) for ASD children who started oral hygiene management from 3 years of age. The management period was until 6 years of age. As a result, the incidence of dental caries was associated with adaptation to tooth brushing. Moreover, adaptation to tooth brushing was associated with the sensitivity to sense of touch stimulation and the developmental age based on item analysis. Thus, ASD children who are sensitive to touch stimulation or have a low developmental age have difficulty adapting to tooth brushing, and therefore often develop dental caries. These results suggest that careful oral hygiene management is needed when ASD children have difficulty adapting to tooth brushing. For children who are sensitive to touch stimulation or have a low developmental age, measures to prevent dental caries, such as reinforcement of professional care, are needed because of their difficulty adapting to tooth brushing.
Lesch-Nyhan syndrome is associated with repeated self-injurious behavior to the lower lip, buccal mucosa and tongue. Therefore, dental support to prevent self-injurious behavior of the oral cavity is important. The case was a 1 year 11 month old boy with Lesch-Nyhan syndrome who came to our hospital in the hope of specialized oral management. Self-injurious behavior to his lower lip was observed at 2 years 3 months. A mouthguard for the upper jaw was used to prevent his self-injurious behavior, but it was not successful. At 3 years 3 months, the patient’s crown height was cut on his four maxillary deciduous incisors and the four lower deciduous incisors were extracted. Furthermore, the use of a mouthguard for the lower jaw was planned. In order to exclude the lower lip, a resin was used to add thickness to the labial side of the mouthguard. By the wearing mouthguard and excluding the lower lip to the labial side, self-injurious behavior to his lower lip was prevented. Also, to increase the bite, resin was used to add thickness to the areas of the deciduous molars in the mouthguard. Now, the patient is 4 years 9 months old and the self-injurious behavior to his lower lip has been prevented by continuous use of the mouthguard for the lower jaw. Use of the mouthguard for the lower jaw not only prevented the patient’s self-injurious behavior, but also has improved the mental health of the parents and child.
Habitual temporomandibular dislocation is a common clinical disease, but its invasive treatment is difficult to adopt in elderly people, patients with other diseases, or patients who have difficulty in communication. Herein, we report good results of autologous blood injection (ABI) therapy for habitual temporomandibular dislocation in a patient with Down syndrome who had intellectual disability and difficulty in communication. The patient was a 62-year-old woman. She was admitted to our hospital because of frequent temporomandibular dislocation. Treatment was difficult because of her Down syndrome, intellectual disability, and low tolerance. In consideration of the safety of invasive postoperative management, ABI therapy was performed under immobilization by restraints and medical assistants. The dislocation frequency had decreased to around once a month at 6 months after the operation, and the burden on both the patient and the guardian was reduced. In conclusion, ABI therapy for habitual temporomandibular dislocation in patients with Down syndrome who have intellectual disability and difficulty in communication is considered an effective and less invasive treatment.
Noonan syndrome, which is characterized by a typical face, congenital heart disease, deafness, mental retardation and short stature, is a kind of congenital malformation syndrome. We report on our dental treatment of a patient with Noonan syndrome who had been scheduled to undergo surgery for pulmonary artery stenosis, to prevent infective endocarditis caused by oral infection, under general anesthesia through medical examination cooperation.
The patient was 3 years and 10 months old. Although she received regular oral examinations at a family dental clinic, it was necessary to treat her dental caries before surgery for heart disease. Because she had mental retardation, it was difficult to treat the dental caries while controlling behavior in the awake state, so general anesthesia was used for the dental treatment. However, her systemic condition was high risk in view of the congenital heart disease and systemic management was needed before and after general anesthesia. Accordingly, she visited our dental clinic with a letter of recommendation from the pediatric doctor who worked at the same hospital with us and was the family doctor when she was born.
A preoperative evaluation was carried out in cooperation with pediatric doctors in our hospital in addition to consultation with the family pediatric doctor. After admission to the department of pediatrics in our hospital, dental treatment to remove the sources of oral infection under general anesthesia was carried out. She was discharged from the hospital with good progress of the oral and systemic conditions the next day after the operation.
It is necessary to remove sources of oral infection before heart surgery in patients with congenital heart disease because oral infections such as dental caries and periodontitis are risk factors that may cause infective endocarditis. In addition, medical examination cooperation with family doctors and dentists is important for universal hospitals as tertiary medical institutions because we treat dental diseases in patients who have general diseases and whose dental diseases cannot easily be treated by family dental doctors in their private dental clinics.
There are cases in which adult developmental disorders are overlooked without being diagnosed, and many patients find it difficult to live because the disorders interfere with work, daily life, and communication with the surroundings. We experienced a case in which attention deficit/hyperactivity disorder (ADHD) was diagnosed after referral to a psychiatrist because of the attitude of a patient who visited our clinic for the treatment of chronic pain in the oral cavity. The patient was a 50-year-old woman. She visited our hospital with chronic pain in the right lower mandibular second molar and treatment for pain was started under the diagnosis of myofascial toothache. In the examination room, she was restless, had difficulty speaking in turn, and had strong catastrophic thinking. Since she could not understand and cooperate with pain treatment even after several months, and accurate pain evaluation was difficult, she was suspected of developmental disability and was referred to a psychiatrist. She was diagnosed with ADHD and drug therapy with ADHD drug was started. At present, ADHD symptoms are gradually improving, and active participation in future pain treatment and pain improvement are expected. As in this case, hidden developmental disorders may be obstacles to treatment. It is suggested that it is important to promote consultation with specialists and to cooperate with them in order to provide appropriate treatment.
Stickler’s syndrome (STL) is an autosomal dominant connective tissue dysplasia caused by abnormality of type II collagen. It is associated with progressive ocular and ear disease, and joint problems, midface hypoplasia, cleft palate, and micrognathia. Almost all patients do not have an intellectual disorder, but they need support for eating because of many dysfunctions and disease complications. However, there are no reports on rehabilitation for eating among patients with STL.
We report the case of a girl with STL. She was 2 years and 9 months old at the first visit. The chief complaint from her mother was that she was a picky eater. She had a cleft palate, severe myopia, otitis media with effusion, vertebral epiphyseal dysplasia, growth disorders, overbite occlusion, and narrow palate. During eating, she could chew something, but she seemed to become weary after eating for a long time. The more she ate, the more slowly she chewed. She accepted rice with curry or laver boiled down in soy, and hated crispy food. When she went to the day support center at 2 years and 11 months old, she refused to eat more because of mental and physical fatigue. We instructed her mother to follow three points:first, to change food to her favorite color;second, mealtimes should be 20 minutes;third, whenever the child could eat new food, her mother must compliment her. The child had not been able to eat until 5 years and 10 months old, but she gradually began to try new foods. In this case, her picky eating was caused by sensitivity disorders such as the eyes and ears, orofacial disability with structured abnormality, and feebleness. Support should be provided to prevent eating disorders, including monitoring of temporomandibular arthritis.
It is well known that gingival hyperplasia is caused by hereditary gingival fibromatosis and drugs such as phenytoin, calcium antagonists of nifedipine and amlodipine, and cyclosporine. We report a case of a severely mentally and physically disordered child who was found to have gingival hyperplasia with no drugs and who had no genetic factor.
A 7-year 8-month-old girl had cerebral palsy (spastic type), intellectual disability, epilepsy, and vascular Ehlers-Danlos syndrome. She was not taking any drug that could cause gingival hyperplasia and she also did not have any genetic predisposition to hereditary gingival fibromatosis. Horizontal ridge-like gingival hyperplasia was prominent inside the molars on both the upper and lower jaws. No findings of inflammation were observed in the hyperplasia gingiva. There were no bones inside the gingival hyperplasia. Impacted milk teeth and permanent teeth inside her gingival hyperplasia were observed. Narrowing of the tongue space and vertical positioning of the tongue were also observed. Due to the vertical gingiva expansion, the gingiva at the posterior part of the upper and lower molars came into contact, resulting in open bite with three-finger breadth. After gingival resection, eruption of permanent teeth and reduction of open bite width were observed. However, over time, gingival hyperplasia grew large again. Five years later, gingival hyperplasia was observed to the extent that the gingiva of the left and right lower molars contacted each other. Due to the difficulty of establishing an airway and hemorrhagic diathesis with vascular Ehlers-Danlos syndrome, we could not perform gingival resection. We referred her to another hospital where advanced medical management was possible.
Type 1 diabetes (IDDM) is a disease in which β cells of the pancreatic islets of Langerhans are destroyed by autoimmune deficiency, resulting in an absolute insulin deficiency. Its incidence in children is 1.5-2 per 100,000 annually. A problem of its perioperative management is the difficulty of managing blood glucose levels due to their extensive fluctuations. Herein we report the perioperative management of a type 1 diabetes child with mental retardation. The patient was an 11-year-old girl, who was diagnosed with IDDM based on HbA1c of 12.7% and blood glucose of 343 mg/dl, and was undergoing intensive insulin therapy.
Because she had dysarthria, we planned pharyngeal valvuloplasty under general anesthesia. Before the surgery, glycemic control was performed in our hospital in close cooperation with a diabetic specialist. During the operation, the patient received an infusion containing glucose and potassium, and continuous administration of short-acting insulin. Blood glucose and electrolytes were as necessary and controlled appropriately. She had a hypoglycemic seizure postoperatively but could be well managed without any serious complication.
Congenital anomaly syndrome is the general name for disorders where there are anomalies in multiple organs, and the patients often require respiratory care with tracheotomy due to complications of respiratory disturbance caused by congenital anomalies at birth. This article reports on a case of congenital anomaly syndrome that we experienced, which presented with intellectual disability and tracheal stenosis due to a medical history of tracheotomy during childhood, and which made it difficult to select the behavior modification method as it was impossible to use intravenous sedation or general anesthesia in providing dental treatment.
The patient was a 20-year-old male with congenital anomaly syndrome and severe intellectual disability, and who had received tracheotomy to treat hypoxic encephalopathy at birth. The tracheal cannula was removed when he was 4 years old. The history of his present illness included treatment of multiple dental caries at his regular dentist in January 2009 under manual restraint. However, he was referred to the dentistry department of a general hospital due to large body motions. He was then referred to a university hospital as treatment had been difficult even in the hospital, and was transferred to the dental surgery department of a prefectural general hospital with a request for tooth extraction. Although tooth extraction was scheduled with general anesthesia in September 2011, it was discontinued during tube insertion, since the tracheal tube could not be inserted from the subglottis due to tracheal stenosis. The severity of the dental disorder advanced subsequently, and so the patient was referred to and visited the dentistry department for handicapped individuals of a university hospital in December 2013. Dental treatment was provided successively in outpatient visits under physical restraint. The dental treatment consisted of caries treatment with resin filling for 8 teeth, prosthetic treatment after pulp extirpation for 4 teeth, and tooth removal for 13 teeth. By incorporating behavior therapy as much as possible even under physical restraint, adaptability eventually improved to a favorable level, and treatment with normal methods became possible.
Purpose : Five years have passed since our department was established in April 2014. Since the early days of our establishment, we have been accepting difficult-to-treat disabled persons (children) from other dental clinics. We report our experience, with retrospective clinical and statistical reviews for the past 5 years.
Method : The study examined age, gender, and treatment content for a total of 275 disabled persons who underwent dental treatment under general anesthesia at our institution for the 5 years from April 2014 to March 2019. The study also investigated the types of disabilities and routes of referral.
Results : By gender, the study confirmed 166 male cases and 109 female cases. The average age for the 5 years was 26.5±17.4 years old. By disability, the study confirmed 78 cases of developmental disability, 75 cases of intellectual disability, 29 cases of physical handicap, 3 cases of mental disability, and 90 cases of other disability. The average anesthesia time and average treatment time were 135±71.5 minutes and 112±64.8 minutes, respectively. The total number of treated teeth for the past 5 years was 2,894 while the average number of treated teeth per case was 10.5±6.8. For oral care management after treatment, 131 cases were treated at family dental clinics and 89 cases were treated at a local dental service center for disabled persons.
Conclusion : Although there was demand for dental treatment under general anesthesia due to cooperation with the local community, the number of cases eventually reached a ceiling in 2015 along with waiting patients. In addition, it was found that 80％ of the patients received oral health management at family dental clinics after treatment. The present situation suggests that our hospital serves as a core hospital in establishing cooperation with local dental institutions. In future, we intend to expand the dental treatment system for disabled persons in the local community.
The purpose of this study was to investigate what the parents of schoolchildren with intellectual or other disabilities expect of their family dentists, and to demonstrate the value of regular visits to family dentists to prevent the development of dental caries. Questionnaires were distributed to 227 families with special-needs schoolchildren with intellectual or other disabilities in June 2018. The parents answered questions regarding the presence or absence of a family dentist, frequency of dental visits, the age of the child at the first visit to the family dentist, and the good points of and requests for the family dentist. The caries experience of each child was confirmed from the results of the annual school dental examination in 2018.
One hundred and thirty-six respondents returned the questionnaire (collection rate 59.9%). Of 136 children, 134 had records of the school dental examination and 101 had a family dentist. The results were as follows:
(1) Eighty-four children visited a dental clinic and 12 visited a university hospital at least once a year.
(2) Sixty-seven respondents replied “doctor’s hospitality”, followed by “staff’s hospitality” (64 respondents) and “high expertise in dentistry for the disabled” (49 respondents) as good points of the family dentist.
(3) Sixty respondents answered the question “What do you expect of a dental clinic?” Key words were picked up from the text replies and classified : frequently-mentioned key words were those related to “high expertise in dentistry for persons with disability”, “hospitality toward the patient” and “waiting time considerations”.
(4) There was no significant relation between the presence or absence of a family dentist, type of dental institution or caries experience of children with intellectual disability.
Elderly people requiring nursing care may develop a fever and suffer pneumonia due to increased aspiration volume, dehydration, and decreased immune function；it is important to prevent fever in the elderly requiring care. This study aimed to determine the relationship between fever and the patient’s background and oral findings in elderly people requiring nursing care with tube feeding. The subjects were 16 elderly patients requiring nursing care who were tube-fed and who had not been ingesting anything at all. The age, disease, nutrition intake, bedridden degree, fever within the past 6 months, consciousness level （Japan Coma Scale）, and ability to communicate were confirmed from hospitalization records. Patients with a fever and body temperature of above 37.5℃ were evaluated. Membranous substances on the palate collected from the palate mucosa were confirmed pathologically to have an epithelial component present. The simple correlation with fever was analyzed by Fisher’s exact calculation, Chi-square test, or Student’s t-test.
There were no statistically significant differences between age, sex, bedridden level, level of consciousness, communication ability, disease, residual teeth, carious teeth, CPI, and fever. There was a significant difference between the presence of membranous substances on the palate and fever. The ratio of elderly people who had a fever was substantially higher for those with membranous substances. The oral cavity and respiratory tract with membranous substances present tended to be dry. Dry mouth and dry respiratory tract cause local immunological weaknesses and have specific bacteria, which are suspected to cause fever. To prevent fever in elderly people requiring nursing care with tube feeding, it is suggested that oral care and moisturizing mucosal care are important.
To gather feedback from parents regarding the method of physically restraining their children during dental treatment and to improve the operation of dentistry for patients with special needs, a questionnaire survey of parents was conducted regarding physical restraints during dental treatment in a center where general anesthesia and intravenous sedation cannot be performed. The dentist explained to the parents about the method of physical restraint during dental treatment, why physical restraint was necessary, the danger of the method, and also introduced a tertiary medical institution where general anesthesia/intravenous sedation was available if desired. The dentist offered three options：“A. Okay. I want treatment under restraint （restrainer）”, “B. Okay, but I want treatment that can be done without restraint”, or “C. Okay. I would like to be referred to a tertiary medical institution （university hospital）”. After the parents selected a choice, the dentist distributed a questionnaire form and asked them to fill it in anonymously.
The questions were：（1） Previous experience of a physical restraint net （restrainer） when your child received dental treatment, （2） Thoughts on treatment using restraints, （3） Further choice for selected behavior management.
89.1％ of parents had experienced physical restraint of their children, wanted it, and thought positively of it. The other 10.9％ of parents wanted treatment without the use of physical restraint. In special needs dentistry, it is important to create an environment that makes it easy for parents to talk to their dental staff about what they want and about any worries they may have. Also, it is important to respect the thoughts of parents and always provide them with the opportunity to choose which behavior management method should be applied during each and every treatment.