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Ann-Marie C. DePalma, CDA, RDH, MEd, FADIA, FAADH, is a graduate of the Forsyth School for Dental Hygienists, Northeastern University and the University of Massachusetts Boston. Ann-Marie is a Fellow and Certified Educator of the Association of Dental Implant Auxiliaries (ADIA), a Fellow of the American Academy of Dental Hygiene (AADH), a continuous member of American Dental Hygienists’ Association (ADHA), as well as a lifetime member of the American Association of Dental Office Management (AADOM). She is the 2017 Esther Wilkins Distinguished Alumni of Forsyth Award recipient. Ann-Marie has been published in dental and dental hygiene publications and textbooks. She is a consultant dental hygiene examiner for CDCA (Commission on Dental Competency Assessments formerly the Northeast Regional Board). She is currently a Technology Advisor for Patterson Dental educating teams on software technology for their practice and patients. Ann-Marie presents continuing education programs for dental team members on a variety of topics. She has been employed as a business/clinical advisor for a national dental practice management company, a faculty member of a dental hygiene program and program chair of a dental assisting program after having been employed in clinical hygiene for a number of years. Ann-Marie can be reached at firstname.lastname@example.org
There are many things dental professionals can do to educate and help children with developmental delays and their families.
Your first patient this morning is a two-year-old boy whose parents have been long time patients in your practice. This will be Michael’s first visit to the dentist and you are excited to meet him after hearing all about him from his parents. Yet when mom and he arrive, something doesn’t seem right. He doesn’t say much, pointing at various items instead of saying words, although he seems happy. Your pediatric medical history asks questions about birth history and mom noted that he had been in NICU (neo-natal intensive care unit) for several days after he was born for a minor medical issue but otherwise was a healthy two-year-old. His pediatrician had said he was growing normally, but mom was concerned and didn’t know what to think. She had heard that by age 2, he should be putting words together and respond to 2-part commands, but she noticed that he really didn’t “talk” much and mostly pointed. What would you advise?
Identifying and Educating
As dental professionals we are the educators for all our patients, from the very youngest to the oldest. Patients look to us for guidance, often for both dental and non-dental issues. With Michael and his mom, we can provide referral to the professionals that are accustomed to developmental delays in children. A developmental delay is defined as when the child’s skills are developing slower than normal. Many children exhibit delays, especially pre-mature infants, but they often catch up to their peers over time. A developmental disorder is one where the child’s skills are developing abnormally or not at all. Developmental delays can be exhibited in language/communication, fine and gross motor skills, cognitive skills, social/emotional well-being, and self-help skills. Each child is an individual and will develop at his/her own rate, but there are ranges for when children should be achieving appropriate milestones in development.
We can recognize these subtle signs, particularly in the area of speech/language and oral motor skills and help the parent/caregiver and child receive the appropriate diagnosis and therapy needed. We are not diagnosing a delay but rather providing information to the family for the benefit of the child. The sooner early intervention or care takes place the better the outcome for the child and family.
We deal with the head, neck and oral cavity, and these areas are particularly important in the communication process. There are also issues involved with motor skills that can be exhibited through the oral facial musculature. How long an infant or young child takes nutrition, beginning with the bottle or breast, all the way to self-feeding, can be an indicator of oral facial muscle imbalances. Speech, which is the motor act of sound production, involves phonation, resonation and articulation. Phonation is the sound system that makes up the sound sequences of words, resonation is the rate and rhythm of the voice which can be affected by problems in the breathing pathway, and articulation is the rapid and precise movement of the lips, tongue, cheeks and mandible.
During an initial examination of a child, whether as a lap exam or in the dental chair, reviewing tongue positioning and swallowing, the tonsillar area, the lingual/buccal frenums, thumb sucking or pacifier use, determining if there is any oral sensitivity or other type of sensitivity issues, or if the child breathes primarily through their mouth rather than their nose can guide in determining if a delay is present. These areas may indicate an oral condition that dentistry can treat or can be a sign of other issues that require referral.
Over the past several years as dentistry has gained knowledge regarding sleep apnea, the child who exhibits sleep apnea may also have other issues. As adults can present with certain signs and symptoms, children may exhibit subtle sleep apnea issues that may not be thought of as sleep related. Children who have behavioral problems, mouth breathe, have poor weight gain, exhibit hyperactivity, or bed wet beyond normal age appropriateness, may be exhibiting sleep apnea concerns.
Children presenting with underdeveloped play skills for their age, have no simple phrases by age 2, provide inappropriate responses to questions, tend to overstuff food in their mouth or speak unintelligibly so that others beyond their immediate family understand them, may be at risk for a communication delay. For younger children, the issues may not create a problem, but as the child ages and communication or motor skills are lacking behind age appropriateness, it can become an issue.
For children age 3 to age 5, depending on state rules and regulations, the state’s early intervention (EI) program is the appropriate referral source for any concerns. Every state offers early intervention screening for children within their age ranges but not all children can qualify. Qualifications are based on family and social situations and the child’s medical history. For example, a child who has spent time in NICU may qualify for services while a child who has no medical concerns other than a delay in speech may not. Early intervention is a family focused program where a family educational plan incorporates services for the child and involves the family in those services. Once a child reaches the state’s age limit and services are still required, the local school system’s special education department (SPED) becomes the source of service. However, the SPED program only provides the child with services and treatment during school time and establishes an individual educational program for the child. Both the FEP (family education plan) and the IEP (individual education plan) focus on the goals and objectives that therapy and services achieve.
Beyond the formalized programs, the dental professional can provide appropriate treatment by a myofunctional therapist, dental sleep therapist or oral surgeon depending on the diagnosis for the child. Dentistry can work in conjunction with EI or SPED programs and medical providers such as ENTs or can provide services alone. Most EI or SPED programs do not have dental professionals on their formal teams but can refer to appropriate resources. Being a resource for your local programs enhances the practice’s visibility as a healthcare profession.
With Michael, mom was receptive to learning about EI and a referral was made. His diagnosis was moderate speech/language delay and a slight motor delay. He received appropriate treatment until he aged out of the program at age 3 when he began pre-school. He received some services in pre-school but was deemed by the end of the academic year to be at age-appropriate levels and services were discontinued. Yet, many parents/caregivers are reluctant to admit there may be an issue with their child. Having questions on the practice’s pediatric medical history regarding mealtime, sleep and communication can open the door to conversations with parents/caregivers. Never interrogate a parent about the child’s condition, let him/her guide the conversation by asking if they have any concerns both dental or non-dental about their child. Offer information in the reception or consult area for parents; there are a variety of resources available both in paper and electronic format. Have the contact information available for your local EI and SPED programs. Use appropriate American Dental Association (ADA) Code on Dental Procedures and Nomenclature (CDT) for services rendered, for example, D0145, oral evaluation of patient under 3 years of age with counseling of primary care giver.
Providing referrals to appropriate early intervention programs provides the practice and team with knowing they have taken a small step in medical/dental collaboration which in turn helps alleviate frustration and concerns for parents and children. A win-win for all.