BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 339
Managing patients with SHCN includes proper coordination
and transition into adult care. Pediatric dentists are concerned
about decreased access to oral health care for patients with
SHCN as they transition beyond the age of majority.
35
Finding
a dental home for nonpediatric patients with SHCN can be
challenging. Pediatric hospitals, by imposing age restrictions,
can create another barrier to care for these patients. is presents
diculties for pediatric dentists providing care to adult patients
with SHCN patients who have not yet transitioned to adult
primary care. Outpatient surgery centers and in-oce general
anesthesia may be alternatives, although they may not be appro-
priate for patients with medically complex special needs.
36
e
Commission on Dental Accreditation requires dental schools
to ensure that curricular eorts focus on educating students
on assessment of treatment needs of patients with SHCN.
37
Recommendations
Reducing the risk of developing oral disease is an integral
part of the comprehensive oral health care for children with
SHCN. e goals of care include: (1) establishing dental
home at an early age, (2) obtaining thorough medical, dental,
and social patient histories, (3) creating an environment con-
ducive for the child to receive care, (4) providing compre-
hensive oral health education and anticipatory guidance to
the child and caregiver, and (5) providing preventive and
therapeutic services including behavior guidance and a multi-
disciplinary approach when needed.
6
Attention to detail is
important for all aspects of care including scheduling appoint-
ments, assessment, treatment planning, consent, education
and anticipatory guidance, treatment, recalls, and transition of
care when the patient reaches adulthood.
Dental home
A dental home should be established by 12 months of age,
38
especially for children with SHCN. e dental home provides
an opportunity to implement individualized preventive oral
health practices, help establish routine dental care, and reduces
the child’s risk of preventable dental/oral disease.
38
Dentists
are obligated to be familiar with the regulations of the Amer-
icans with Disabilities Act
18
(AwDA) and ensure compliance.
Regulations require practitioners to provide physical access
to the dental oce (e.g., wheelchair ramps, disabled-parking
spaces).
Scheduling appointments
The caregiver’s and patient’s initial contact with the dental
practice allows both parties an opportunity to address the
child’s primary oral health needs and to conrm the appropri-
ateness of scheduling an appointment with that particular
practitioner. Along with the child’s name, age, and chief
complaint, the receptionist should determine the presence
and nature of any SHCN and, when appropriate, the name(s)
of the child’s medical care provider(s). e oce sta, under
the guidance of the dentist, should determine the need for an
increased length of appointment and/or additional auxiliary
sta in order to accommodate the patient in an eective and
ecient manner. e need for increased dentist and team time
as well as customized services should be documented so the
office staff is prepared to accommodate the patient’s unique
circumstances at each subsequent visit.
39
Consideration for
length of time, time of the appointment (e.g., morning, rst
appointment of the day, limited patients in the waiting room)
or need for introductory visits helps to ensure a positive
experience.
6
When scheduling patients with SHCN, familiarity and
compliance with Health Insurance Portability and Account-
ability Act (HIPAA) and AwDA regulations applicable to
dental practices are imperative.
18,50
HIPAA insures that the
patient’s privacy is protected, and AwDA prevents
discrimination on the basis of a disability.
Patient assessment
Familiarity with the patient’s medical history is essential. An
accurate, comprehensive, and up-to-date medical history is
necessary for correct diagnosis, eective treatment planning,
and decreasing the risk of aggravating a medical condition
while rendering care. e intake interview should address the
chief complaint, history of present illness, medical conditions
and/or illnesses, medical care providers, hospitalizations/surgeries,
anesthetic experiences, current medications, allergies/sensitivi-
ties, immunization status, review of systems, and family, social
and dental histories.
41,42
e interview should include patient’s
development, education level, and cognitive ability to help
predict cooperation.
32
Many children with SHCN may have
sensory considerations or limitations to communication that
can make the dental experience challenging; the dentist should
include such concerns during the history intake and be pre-
pared to modify the traditional delivery of oral care to address
the child’s unique needs. If the patient/parent is unable to
provide accurate information, consultation with the caregiver
or with the patient’s physician may be required.
At each patient visit, the dental team should consult and
verbally update the patient’s medical history, noting any recent
medical attention for illness or injury, change in health status,
newly diagnosed medical conditions, allergies/sensitivities, and
changes in medications. Obtaining a written update at each
recall visit enhances documentation and awareness of the
patient’s history and health status. e patient’s record should
identify any signicant medical conditions.
A comprehensive clinical examination includes evaluation
of the head, neck, and oral structures, along with caries- and
periodontal-risk assessment.
43,44
Caries-risk assessment pro-
vides a means of classifying caries risk at a point in time and,
therefore, should be applied periodically to assess changes in
an individual’s risk status.
43
e examination also should in-
clude assessments of occlusion, habits, and traumatic injuries.
e dentist should review all available adjunctive diagnostic
aids such as radiographs, photographs, or blood tests.
A summary of the oral ndings and specic treatment
recommendations should be provided to the patient and parent.