okay we're into chapter 51 the patient with a disability as you know disabilities can impact daily activities and function of an individual people with disabilities may require a modified approach to oral health care in order to achieve and maintain oral health and prevent rampant dental disease so the intention of this chapter is just to provide General guidelines for modifying dental hygiene care for a patient with disabilities so the learning objectives can be found at the start of each chapter again I encourage you to look at these learning objectives before you start studying the chapter it's going to help direct your focus and you will do well on tests and the other suggestion of course when preparing for test always pay attention to the boxes that are that have gathered all the important information out of the chapters and they make boxes so they're easy to understand if I was going to make note cards I would absolutely include the the boxes that are included in each chapter okay so this is the disabilities overview so some some important statistics take from a 2017 disability statistics annual report that's put out by the University of New Hampshire you need to know this it's an estimated 10.5% % of people between the ages of 17 and 64 5.4% of children between the ages of 5 and7 and of course with age disabilities will increase so it is 35.4% for those 65 and older progress in medical care has increased initial survival of those born with disabilities and increase the survival rate of those experiencing a disabling condition advances in medicine have increased the lifespan of people with comorbidities that would have shortened their lifespans as life expectancy increases so does the likelihood of acquiring a disability you need to be introduced to the Americans with Disability Act uh and know that it's different when we're talking about it here than the the Ada which we're all well aware of at this point but the American Dental Association of course but this is the Americans with Disability Act so the purpose is it's a civils civil rights legislation that was enacted into law back in 1990 that prohibits discrimination and guarantee that people with disabilities have the same opportunities as everyone else to participate in the mainstream of American life to enjoy including employment opportunities to purchase goods and services and to participate in state and local government programs and services you need to know the definition 8 a defines an individual with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activities has a record of such impairment and is regarded as having such a such an impairment major life activities include but are not limited to caring for oneself performing manual tasks seeing hearing eating sleeping walking standing lifting bending any movement basically and definitions and classifications disability is an umbrella is an umbrella term for impairment activity limitations and participation restrictions impairment refers to a problem with a body structure or function important to note here disabling conditions can be developmental communicative medical must muscular skeletal neurologic or sensory you want to be really careful when taking the first exam you want to pay attention to the presence of an absolute in a sentence like such as using the word any keep in mind that any loss or any abnormality would include minor injuries such as illness or deformities that don't affect daily life so when you're when you see that keyword any in in the test imagine somebody having web toes so people with disabilities are the most underserved groups in receiving dental care and have the most significant oral health disparities of any group progress now is being made to ensure adequate access to dental care but barriers exist related to the patient family caregivers Guardians and dental professionals again you can review this table you should know this on it's the table 51-2 having adequate access to dental and dental hygiene Services can make a significant contribution to oral health well-being Independence and sense of personal esteem of a patient with disability although providing care for patients with disabilities is challenging training experience empathy patience and a desire to be successful will help so Trends in communitybased delivery services so Trends individuals with physical and intellectual impairments may be self-sufficient or may have community-based living educational and work arrangements barrier-free or Assisted Living housing for individuals and staffed community-based residential facilities for group living are available for those who need daily assistance then we have many uh home care and Community Based Services that are available for individuals we have new healthcare delivery System Mod models that are being proposed to provide access to dental services where people live work play or go to school or receive other social services think of our mobile unit that's coming aboard um that we will be getting in October which is really exciting expansion of direct access so regulations increase the ability of dental hygienist to provide preventative Services and alternative settings and function as members of interprofessional patient care teams again uh review chapter 4 for more information on that a barrier-free environment so Healthcare facilities are required to follow guidelines specifications for a barrier-free physical environment this is based on governmental regulations for accessibility standards in general a facility that is barrier-free for a patient in a wheelchair is accessible to all other individuals so you need to know about external features the parking you need a reserved area we all know that um clearly marked near the building entrance it has to be 13 ft wide you're not going to be asked a question specifically on the parking other than that you need to know that we that it is required curb ramps but are which are cutouts from the streets and from from the parking area walkways so walkways don't confuse this with doorways walkways it's a 3ot wide walkway that's needed for a wheelchair accommodation surface should be solid and nonslip and should not have any irregularities so the entrance at least one entrance entrance to the building has to be on ground level accessible by a gently sloping ramp so you don't need the to know the rise but it is 1 in for every 12 in an easily grasped handrail that's needed on both sides to accommodate accommodate left and right-handed people the door the lightweight door with a a lever type of handle opens at least 32 in 32 in now this is doorway remember I told you don't confuse this with the walkway so 32 in for a person using a tall crutch and for a wheelchair internal features official regulation specified dimensions for accessibility of all aspects this includes passageways floors drinking fountains and restrooms and you should review that um again doorways you need to to know this for your test doorways are at least 32 in wide so we're going on to risk assessments so the medical we'll be talking about the oral manifestations functional ability and medical stat so oral manifestations people with disabilities have an increased risk for oral problems such as enamel defects High lip lines which can lead to dry gingiva variations in number number of size or shape of teeth facial asymmetry you see the picture in the upper left hand corner um hypoplasia of the mid facial region or the cleft lip or pallet also damaging oral habits such as bruxism mouth breathing tongue thrusting self-injurious Behavior rumination which is the regurgitation of chewed food and paa paa is eating unusual objects and substances such as cigarette butts or sand functional ability so that refers to the ability of an individual to accomplish daily living skills particularly bathing toothbrushing dressing things like that we should be addressing we should be assessing the functional ability for all of our patients ask them what they're able to do and what they need assistance for at home so you do need to know this is a test question an individual patient's functional level may be affected by a decrease in cognitive of capability behavioral problems Mobility problems and uncontrolled movements wheelchair accessibility wheelchairs designed for adults vary in width from 2 3 in to 2 8 in a clear clear door width of 32 in to accommodate these wheelchairs have or has been accepted as the official regulation so 32 in to accommodate those wheelchairs just keep that in mind so oral disease prevention and control so you can see by the pictures we'll be talking about providing regular professional exams at treatment intervals that are established by the patient's level of risk for oral disease motivate the patient and caregiver contribute to the patient's General Health through preventing to uh tooth loss maintaining ability to masticate food prevent the need for extensive dental and parodontal treatment that the patient may not be able to undergo prevent the need for dentures or other removable proses Aid in personal appearance the perception of oral health status and social acceptance without hosis preventative care introduction depending on the disability and level of function the patient may need complete assistance partial or maybe no assistance with daily bofilm removal it's imperative that the caregiver is educated on the best way for the patient to take care of his oral cavity so oral disease prevention and control pit and Fisher sealant the principles for application are the same as those for use of a dental assistant is imperative to help with patient management enhance ability to maintain a dry field to assure sealant retention use of a rubber Dam when possible when a severely disabled patient will be administered general anesthesia for restorative procedures pit and fixture pit and Fisher sealants are placed in all noncarious accusal pits and Fishers at that time and diet instruction that's really easy um until well you have taken a nutrition course before coming to this program so you do know that any processed food or overeating of processed foods is a problem so you can always steer them to uh natural natural foods so untouched Foods pull Foods so here's some examples for aids for patients who cannot grasp and hold their toothbrush you can see the one there's a wrist band or handband and you can see the flosser you I think we have those samples in the clinic you also have the this fold over band that just snaps on their hand on on the palm of their hand that which makes the toothbrush a little more sturdy so they can they don't have to really move their hand overly much it's they can move with their arm and then of course somebody who didn't buy any of these special things they can make their own with a little rubber band and tie it on each end this is AIDS for patients with a limited grasp that maybe somebody with rheumatoid arthritis who has trouble grasping and holding on to things or squeezing tightly uh they can make these at home using an old bicycle handlebar grip um a tennis ball or maybe an old can with a ball stuffed in the top as you can see at the bottom if they can hold on to that can a little bit easier and you can recommend these to your patients and some people have really limited uh dexterity or or problem reaching to the posterior portions of their mouth they do make a special toothbrush that actually wraps around the whole teeth the whole tooth and the whole uh sexon or quadrant dental floss holder we saw that and we Al uh a few slides back and we do have the samples here in the clinic hopefully if we're doing this lecture in class we can bring out these additional helpers for everybody to see but the use of the floss holder is recommended for those that are having trouble wrapping it around their fingers and you just have to assess your patient to see if that would be helpful denture brushes with suction cups again that's very helpful for somebody with limited Mobility they can will their chair right up to the sink and put put the sink put the suction on the sink and actually move the Denture back and forth to clean it that is very helpful for some people patient management we'll be going over the objectives uh communication pre-treatment planning appointment schedule introduction of clinical settings Continuing Care appointments assistance for the patient whose ambulatory patient positioning supportive and protective stabilization forehanded dental hygiene instrumentation and pain and anxiety control so do I have any notes Here no as always though patient management um patient positioning objectives for this during treatment are to let the patient feel comfortable while the clinician provides care in a position that provides adequate illumination visibility and accessibility so as a clinician though I I do want you to know that sometimes when we are working on somebody who cannot lean all the way back or especially working in the maxilla region of the mouth you will be at an awkward angle and you don't want to be at that angle for long periods of time you can make short shorter appointments for these patients because standing like that is very very hard on your neck upper back you may want to make four short appointments to work on your patient and I'm not talking four four quads of SRD I'm talking about uh just a standard proy you may want to make four different appointments depending on how hard it is for you to get into the mouth of course if it's just going to extend the appointment just a little bit that you don't want to do that it just depends on how severe it is for you to work on them you do have to take into consideration yourself and your own body but at the same time provide uh care if your patient is up for it you can just shorten the visits uh so with that said adapt the chair position please get into the habit of Leaning your patient all the way back I can't tell you how many times in a clinic session that when I come over the and I I'm checking the upper right quad and the patients in the position that they were in during the whole treatment or maybe the upper anteriors specifically but the student has them has them practically sitting upright so that is not going to promote longevity in this career so you want to be very careful and mindful of that aspect lean your patient back especially if they're young and healthy lean your patient back so something you need to know for somebody who comes in that let's say has a spinal injury so somebody who has a spinal injury and they are able to move theirselves with with the with the arms and hands they have movement full full range of movement with their arms and hands they're able to do a pushup and and they like push up on the on the handles and and they adjust um maybe they're numb on the on the buttocks so they can move that around a little bit this will promote good circulation and it is considered a preventative measure for for de uh dupus decubitus ulcers you need to know that word dupus ulcers is another way to say bed sores which I'm sure we've all heard of it's where somebody has not shifted their weight it has cut off circulation at that point and the tissue begins to die so uh decubitus ulcers is a particular consideration during long dental procedures so you want to the somebody who actually is quadriplegic will be able to possibly shift a little bit maybe they'll need to be adjusted um the caregiver can help you or give you tips on how to do that at any rate communication is very very valuable here so you want to have good communication skills with the the patient and if they're unable to communicate what they need then definitely a caregiver which comes to the point by the way if you have somebody who is a Guardian there is paperwork that needs to be filled out before they're seen in clinic this is the same as if the child is under 18 so with somebody who is incapacitated and using a wheelchair you need to know how to safely prepare and transfer a patient from wheelchair to a dental chair there are different ways but before we get into talking about actual transferring a patient you really need to take into consideration and not be afraid to ask the patient if they're able to to support themselves when they stand up some people can support themselves to a certain extent but are very quick quickly May quickly lose the ability to stand stand up straight so they may fall over which would be terrible not only for the patient but for the person who's trying to catch them as they go over so keep that in mind have clear communication with your patient so that you can offer a adequate assistant so we'll be talking about the mobile patient transfer immobile patient transfer sliding board transfer and the wheelchair used during treatment of course that would be somebody because we're not uh we're not going to lift somebody up out of the chair maybe they're too too big so here's a picture of the wheelchair transfer so a you want to position the wheelchair at a level of or lower than the dental chair set the wheel locks remove the foot rest and arm rests and then raise the dental chair arm the clinician will place the feet outside of the patient's feet grasp the patient around the waist or under the arms lock hands or grasp a belt in the back of the patient and the patient can hold the clinician around the shoulders or neck patient lifted up and pivoted to the dental chair side patients gently lowered to sitting position Dental chair arm is lowered clinician grasps legs together to lift onto Dental chair so that is somebody with a little bit of ability to stand you would not do this to somebody who could not and with that in mind we actually have two different straps that are rolled up in uh in the the AL Cove where the the dentist sits in one of those little plastic drawers there are two straps and these straps of course one is for a smaller person the other one's for a large person you can use that that strap to go wrap it around behind and you're still doing the same move movements except you can step back a little bit further and you can use your body weight to help them lift up again always put a little Bend in the knees do not use your lower back here's a a nice the next one's a transfer board so this will be used by somebody who has limited Mobility sometimes a patient will bring one um we do not have one on hand we but we do have the straps but if a patient is used to using one they may bring their own you want to position the wheelchair again it's alongside the dental operatory chair you want to move the arms out of the way and it needs to be parallel and you to adjust the sliding board the patient or clinician placing sliding board board well under the hip of the patient the board's extended across to the dental chair patient will shift their weight balances on hand and walks the buttocks across the board the CL clinician can assist or do the transfer by holding the patient under the underarms two persons are needed when the patient's heavy or less mobile and the board is removed and replaced after the appointment so what is important to know about this transfer chair well think of the the board as a slide and imagine this this won't be true actually but I just want you to imagine for the test so that you can remember this so let's say they're sitting in the wheelchair the dental or the operatory chair needs to be slightly lower that way makes it easier for the patient to scoot in a downward motion towards the dental chair and then when you're done with the appointment you want to raise the operatory chair a little bit higher than the wheelchair to slide back across so that is important to note I hope I put a good visual into your mind and of course for the person who um you just will not be able to move into the operatory chair maybe it's their size maybe it's their by their request um there are some people that actually are in special wheelchairs we have a portable headrests that can be attached to the wheelchair itself so you can actually treat them in the chair biofilm control so you know bofilm control is very important um if we had a facility for the patient like in an orthodontist office where the uh the children go in or the adults and they brush their teeth before they're seen by one of the CL Ians the tabletop and wash bin in a patient instruction area or laboratory are built at a height of 32 to 34 in to provide clearance underneath for the knees of the patient and arms of the wheelchair a magnifying mirror preferably on a pedestal that tilts can provide an excellent aid for viewing the disclosed bofilm and the devices for bofilm removal so of course anything hot or sharp needs to be covered or insulated because patients with no sensation could be burned or cut instructions for caregivers individuals who need partial or Total Care present with varying degrees of ability to cooperate depending on the type of disability so we need to talk to the caregiver and we need to understand what the self-care attit itude is of the patient and of the and get a general feel of what the relationship how how the communication is between the caregiver and the patient whenever possible instruction for the parents family members or other caregivers begins with their own personal Oral Care Success comes when those who care for the patient have knowledge and understanding of the purposes and techniques they can demonstrate their own bofilm removal and are motivated for self-care so positions or child uh for children with that are disabled it's helpful if you have two people that can help when when it's time for Oral Care especially with somebody who doesn't really want to have it done but here are some great positions you can recommend to your patient um with with with a child you can see in the first upper left corner the maybe the mom and the child where he's actually letting the mother clean clean his mouth in the second image maybe she's having to hold his hands back maybe the hands are going up in in you know maybe not allowing her to get in there and you could see see that's a comfortable relaxed position it seems all calm and D that is when the husband or the father or a partner gets home and helps helps anytime you get a second person involved it makes life a little bit easier these are demonstrations that you could show a patient if they were having trouble getting in and cleaning a child's mouth so you C uh you can also attend and you can also hold group inservice education which they're provided for teachers registered nurses other health professionals parents and Volunteers in school and Community preventative programs this can be take this can take place in the classroom and in in Extended Care institutions the dental hygienist is able to work with caregivers to teach them appropriate techniques and to motivate them to incorporate Oral Care into the daily routine for each resident or patient so of course doing this you will be doing more of this actually in your community class which is in the last semester Tanya is teaching that you will be actually going to uh rest homes or maybe elementary schools wherever you choose and you'll be doing in a a group presentation so this is exactly what they're talking about it's a group inservice education it'll be planning use of Clinic records uh program content you'll need to have that outlined and make it age appropriate so it depends on you know if you're going to a rest home you want to make sure that you have care for um the dentures and proses and when you're in the children's in the elementary school you want to teach them about bofilm removal the very Basics then we're going to talk a little bit about a dental hygienist who actually has a a disability this is not necessarily an obstacle to dental hygiene lure and pro uh provision of clinical care adaptive technology tax incentives for accessibility construction and creative thinking can facilitate any necessary workplace modifications additional dental hygiene roles such as manager Advocate or educator May provide employment opportunities for the dental hygienist with a disability documentation individualize information about the patient condition or level of functioning that will affect modifications needed during dental hygiene care specific details related to patient management or communication strategies used during the dental hygiene appointment and indication of whether or not those strategies were successful factors to teach the patient seek regular dental medical exams learn about disability medications early warning warnings of complications of disease recognize the side effects of treatments and medications seek immediate medical attention for any complications practice a healthy lifestyle practice meticulous oral hygiene and ways to overcome barriers to dental care