Dental patients with special needs are people with different systemic diseases, multiple disorders or severe physical and/or mental disabilities. A Medline search was made, yielding a total of 29 articles that served as the basis for this study, which offers a brief description of the dental intervention protocols in medically compromised patients. Dental treatment in patients with special needs, whether presenting medical problems or disabilities, is sometimes complex.
For this reason the hospital should be regarded as the ideal setting for the care of these individuals. Before starting any dental intervention, a correct patient evaluation is needed, based on a correct anamnesis, medical records and interconsultation reports, and with due assessment of the medical risks involved. The hospital setting offers the advantage of access to electronic medical records and to data referred to any complementary tests that may have been made, and we moreover have the possibility of performing treatments under general anesthesia. In this context, ambulatory major surgery is the best approach when considering general anesthesia in patients of this kind. The dental management of patients with special needs, whether medically compromised or with severe disabilities, is sometimes complex and requires a multidisciplinary and integral approach. The hospital is therefore the ideal setting for treating these patients, due to the availability of specialized technical and human resources found in such centers.
The hospital setting allows dental practice to interrelate with other clinical and surgical specialties, and offers the support of central or core services that can facilitate diagnosis and treatment. Such interrelation is particularly relevant with the Departments of Oral and Maxillofacial Surgery and Stomatology; indeed, the Hospital Dental Surgery Unit sometimes forms part of such Departments (1).
Although most forms of dental care in special patients are provided by the public primary care services, there are certain situations in which hospital resources are needed in patients of this kind. Examples include the use of general anesthesia in the treatment of certain patients with serious physical or mental disabilities when behavioral control proves very difficult, when dental treatment must be completed in a single session, or when there is a strong possibility of medical emergencies developing during the intervention. In this sense, the Hospital Dental Surgery Unit can serve as a link or bridge between the primary care setting and the specialized Department of Oral and Maxillofacial Surgery (1).
Hospital Dental Surgery Units should carry out integral activities such as the diagnosis and treatment of oral mucosal lesions, the diagnosis and treatment of orofacial pain and of temporomandibular joint disease, oral surgery, the dental treatment of medically compromised patients such as those subjected to radiotherapy for head and neck tumors, the use of diagnostic and management protocols in patients programmed for organ transplantation, and the integral dental care of patients with severe disabilities using general anesthesia. Likewise, these Units should facilitate dental interconsultations and attend dental emergencies in long-stay hospitalized patients (1,2).
Logically, these Dental Surgery Units should be structured in accordance to the reference or recruitment population of the centers to which they belong, and in concordance with the available resources, the objectives of the Health Department, and the range of services to be offered to users.
Go to: Material and Methods An electronic Medline search was made, based on the following key words: special patient, special care and hospital dentistry. The search included review articles and adequately designed clinical trials. We excluded clinical cases, clinical trials with methodological shortcomings, and articles unrelated to special patients. A total of 28 articles were identified, as well as one book chapter, which were used as the basis for the present study.
Go to: Medical risk evaluation in hospital dental practice dental patients with special needs are people with different systemic diseases, multiple disorders or severe physical and/or mental disabilities. In these patients we need thorough knowledge of the buccodental impact of their background disease, and must provide dental care that does not adversely affect their general health. In order to provide specific and integral management in these cases, appropriate means and personnel are needed (3).
Before starting any dental treatment, we need a correct anamnesis, medical records and interconsultation reports in order to know as much as possible about the problems of the patient. In this context, the hospital setting offers the advantage of access to electronic medical records and to data referred to any complementary tests that may have been made (3).
The medical risk also must be evaluated before starting any treatment in these patients. To this effect we use the ASA scoring system developed by the American Society of Anesthesiologists (4). This classification contemplates 6 scores according to the patient background illness.
Specifically, ASA I includes healthy patients able to walk up at least one flight of stairs without problems, and who suffer little or no anxiety. Very young or very old patients are excluded.
ASA II in turn corresponds to patients with mild systemic disease, including smokers without chronic obstructive pulmonary disease (COPD); slight obesity; slightly elevated blood pressure controlled with medication; thyroid gland disorders; type II diabetes controlled with diet or drugs; asthmatics who occasionally use inhaled medication; stable chest pain (except if under extreme stress); very anxious patients with a history of fainting episodes in the dental office; patients with myocardial infarction in the previous 6 months but without symptoms; and patients over 65 years of age.
ASA III refers to patients with serious systemic disease limiting daily life activities, such as individuals with type I diabetes; morbid obesity; chest pain with clinical manifestations in response to minor physical exertion; systolic blood pressure between 160-194 mmHg and diastolic blood pressure between 95-99 mmHg; patients subjected to chemotherapy; COPD (bronchitis and emphysema); swelling of the ankles (heart failure); hemophilia; frequent asthma attacks or seizures; and patients with myocardial infarction in the previous 6 months but who still present symptoms.
ASA IV corresponds to patients with serious systemic disease that poses a constant threat to life. This group includes uncontrolled diabetes; patients with chest pain or shortness of breath while sitting in the absence of physical exertion; individuals unable to walk up a flight of stairs; patients who wake up at night with chest pain or shortness of breath; chest pain that worsens even with medication; patients visiting the dental office with oxygen therapy; individuals with myocardial infarction or stroke in the last 6 months; and individuals with a blood pressure of over 200/100 mmHg. In the case of ASA IV patients, dental treatment should be provided in the hospital setting in order to avoid complications (4,5).
Stress can increase morbidity in medically compromised patients, producing physiological changes (6). It therefore must be regarded as a risk factor in dental treatment, in the same way as very old age, excessive medication use, or the administration of immunosuppressors or anticoagulants. In patients at risk we must ensure good pain control and the use of premedication and sedation techniques to control anxiety (3,6).