Dr Zarina BaharinPakar Perubatan Keluarga KK Bota Kiri7 th Mac 2012

SPECIAL NEEDS PEOPLE: OKU Definisi OKU Mengikut Akta Orang

Kurang Upaya 2008:- 'Orang Kurang Upaya' termasuklah

mereka yang mempunyai kekurangan jangka panjang fizikal, mental, intelektual, atau deria yang apabila berinteraksi dengan pelbagai halangan, boleh menyekat penyertaan penuh dan berkesan mereka dalam masyarakat.

Klasifikasi

Kurang upaya fizikal Masalah pembelajaran Kurang upaya pendengaran Kurang upaya penglihatan Kurang upaya pertuturan Kurang upaya mental Kurang upaya pelbagai

KURANG UPAYA FIZIKALKetidakupayaan anggota badan samada

kehilangan atau tiada suatu anggota atau ketidakupayaan di mana-mana bahagian badan yang mengalami keadaan seperti hemiplegia, paraplegia, tetraplegia, kehilangan anggota, kelemahan otot-otot yang mengakibatkan mereka tidak dapat melakukan aktiviti asas seperti penjagaan diri, pergerakan dan penukaran posisi tubuh badan. Keadaan ini boleh terjadi akibat daripada kecederaan (trauma) atau ketidakfungsian sistem saraf, kardiovaskular, respiratori, hematologi, imunologi, urologi, hepatobiliari, muskuloskeletal, ginekologi dan lain-lain.

PENYEBAB

-Limb defects (congenital/acquired)-Spinal cord injury-Stroke-Traumatic Brain Injury-Kerdil (Achondroplasia)-Cerebral Palsy

Cerebral palsy

Apakah Cerebral Palsy

Cerebral-cerebrum Palsy-pergerakan

abnormal Ketidakupayaan fizikal

melibatkan pergerakan badan

Non progressive Non contagious

JENIS

PENYEBAB Sebelum Kelahiran Jangkitan dalam rahim ibu mengalami darah tinggi, kancing manis, kurang darah

ketika mengandung pendarahan teruk dan kronik ketika mengandung

Semasa Proses Kelahiran Kelahiran tidak cukup bulan kecederaan semasa lahir lemas semasa lahir jangkitan semasa lahir

Selepas Kelahiran (sebelum berumur 3 tahun) meningitis (jangkitan kuman diselaput otak) – demam kuning Jaundis yang teruk (kemicterus) Kecederaan otak disebabkan oleh kemalangan, penderaan

dan penganiayaan fizikal

Tanda-tanda

•Bayi kelihatan lembik •lewat perkembangan •menggunakan sebelah tangan (hand preference) •masalah menyusu •kerap menangis, meragam, merenggek, tanpa sebab ataupun terlalu diam dan kurang tindak balas rangsangan •refleks primitive yang kekal •sembelit •cepat marah

rencatan akal (kurang kecerdasan) kerencatan pertuturan rencatan penglihatan rencatan pendengaran sawan (epilepsy) kecacatan anggota kecacatan gigi masalah mengenai pernafasan masalah mangenai pemakanan masalah untuk buang air besar atau kecil.

RAWATAN Physiotherapy Occupational therapy Speech therapy Drugs-antiepileptic,analgesics,muscle

relaxants Orthotic devices Braces Standing frame Biofeedback Surgery

Cerebral palsy-Masalah dental PERIODONTAL DISEASE is

common in people with cerebral palsy due to poor oral hygiene and complications of oral habits, physical abilities, and malocclusion. Another factor is the gingival hyperplasia caused by medications.

MASALAH DENTALDENTAL CARRIES is prevalent among people with cerebral palsy,

primarily because of inadequate oral hygiene. Other risk factors include mouth breathing, the effects of medication, enamel hypoplasia, and food pouching.

Caution patients or their caregivers about medicines that reduce saliva or contain sugar. Suggest that patients drink water often, take sugar-free medicines when available, and rinse with water after taking any medicine.

For people who pouch food, talk to caregivers about inspecting the mouth after each meal or dose of medicine. Remove food or medicine from the mouth by rinsing with water, sweeping the mouth with a finger wrapped in gauze, or using a disposable .

MASALAH DENTAL MALOCCLUSION in people with cerebral palsy usually

involves more than just misaligned teeth--it is also a musculoskeletal problem. An open bite with protruding anterior teeth is common and is typically associated with tongue thrusting. The inability to close the lips

because of an open bite also contributes to excessive drooling.

DROOLING affects daily oral care as well as social interaction. Hypotonia contributes to drooling, as does an open bite and the inability to close the lips.

BRUXISM is common in people with cerebral palsy, especially those with severe forms of the disorder. Bruxism can be intense and persistent and cause the teeth to wear prematurely. Before recommending mouth guards or bite splints, consider that gagging or swallowing problems may make them uncomfortable or unwearable.

Malocclusion Bruxism

Oral Trauma Dental carries

Periondotal gum disease

Gingival overgrowth

ACHONDROPLASIA

Apakah Achondroplasia Ketidakabnormalan genetik Autosomal dominan Mutasi DNA sporadik (85%) Berkait dengan usia bapa advance-

>35 tahun Formasi kartilage tidak normal “short stature” : M (131 cm) F (123

cm) 1: 25 000

ACHONDROPLASIA Penyebab: Perubahan DNA Faktor

Pertumbuhan Fibroblast Reseptor 3 Diagnosis -Prenatal Ultrasound:Discordance between

femoral length and biparietal diameter Berlebihan amniotic fluid-Survey skeletal (rangka) -Large skull -Broad hand with short metacarpals and

phalanges -small and squared iliac wings

SIMTOM Abnormal hand appearance with persistent space

between the long and ring fingers Bowed legs Decreased muscle tone Disproportionately large head-to-body size

difference Prominent forehead (frontal bossing) Shortened arms and legs (especially the upper

arm and thigh) Short stature (significantly below the average

height for a person of the same age and sex) Spinal stenosis Spine curvatures called kyphosis and lordosis

DENTAL PROBLEM

Dental problems caused by overcrowding of teeth (especially those of the upper jaw) may occur. Malocclusion (poor bite) often results and makes good oral hygiene difficult. In addition to ordinary dental care, orthodontic treatment may be necessary.

Complications Clubbed feet Fluid buildup in the brain

(hydrocephalus)

Treatment Not known treatment currently

MASALAH PEMBELAJARAN

Masalah kecerdasan otak yang tidak selaras dengan usia biogikal. Mereka yang tergolong dalam kategori ini adalah lewat perkembangan global, Sindrom Down, lembap dan kurang upaya intelektual. Kategori ini juga merangkumi keadaan yang menjejaskan kemampuan pembelajaran individu seperti Austisme (Autistic Spectrum Disorder), Attention Deficit Hyperactivity Disorder (ADHD) dan masalah pembelajaran spesifik seperti Dyslexia, Dyscalculia dan Dysgraphia.

DOWN SYNDROME-Trisomi 21-Tambahan satu kromosom 21-Kerap pada ibubapa yang

meningkat usia kerana berlaku mutasi gen

-Perkembangan fizikal dan kognitif terganggu

-Kecerdasan otak yang rendah: IQ-50

DOWN SYNDROME

Mother20-24-1:156235-39: 1:214>45: 1:19

However 80% <35 yrs old

Paternal >42 yrs

KROMOSOM 44 XX/XY

TRISOMI 21 (45 XY/XX)

DIAGNOSIS-PRENATAL

AMNIOCENTESISCHORIONIC VILLOUS SAMPLINGULTRASOUNDPERCUTANEOUS UMBILICALCORD SAMPLINGBETA HCGOESTRIOLALPHA FETOPROTEIN

SINDROM DOWN

DOWN SYNDROME

BRUSHFIELD EYES

Treatment

screening for common problems, medical treatment where indicated, a conducive family environment, and vocational training can improve the overall development of children with Down syndrome. Education and proper care will improve quality of life significantly, despite genetic limitations.

MASALAH DENTAL-DOWN SYNDROMEPERIODONTAL DISEASE is the most

significant oral health problem in people with Down syndrome. Children experience rapid, destructive periodontal disease. Consequently, large numbers of them lose their permanent anterior teeth in their early teens. Contributing factors include poor oral hygiene, malocclusion, bruxism, conical-shaped tooth roots, and abnormal host response because of a compromised immune system.

MASALAH DENTAL DALAM DOWN SYNDROME Tooth anomalies are variations in the number, size and shape of teeth. People with Down syndrome, oral clefts, ectodermal dysplasia or other conditions may experience congenitally missing, extra or malformed teeth.

TOOTH ANOMALIESCongenitally missing teeth Third molars, laterals, and mandibular

second bicuspids are the most common missing teeth.

Delayed eruption of teethPrimary teeth may not appear until age 2,

with complete dentition delayed until age 4 or 5. Primary teeth are then retained in some children until they are 14 or 15.

TOOTH ANOMALIES

Irregularities in tooth formation, such as microdontia and malformed teeth, are also seen in people with Down syndrome. Crowns tend to be smaller, and roots are often small and conical, which can lead to tooth loss from periodontal disease. Severe illness or prolonged fevers can lead to hypoplasia and hypocalcification.

MASALAH DENTAL-DOWNMEDICAL CONDITIONS. Some problems are manifested in the

mouth. For example, oral findings such as persistent gingival lesions, prolonged wound healing, or spontaneous gingival hemorrhaging may suggest an underlying medical condition and warrant consultation with the patient's physician.

CARDIAC DISORDERS are common in Down syndrome. In fact, mitral valve prolapse occurs in more than half of all adults with this developmental disability. Many others are at risk of developing valve dysfunction that leads to congestive heart failure, even if they have no known cardiac disease. Consult the patient's physician if having questions about the medical history and the need for antibiotic prophylaxis 

COMPROMISED IMMUNE SYSTEMS lead to more frequent oral and systemic infections and a high incidence of periodontal disease in people with Down syndrome. Aphthous ulcers, oral Candida infections, and acute necrotizing ulcerative gingivitis are common. Chronic respiratory infections contribute to mouth breathing, xerostomia, and fissured lips and tongue.

Treat acute necrotizing ulcerative gingivitis and other infections aggressively.

Talk to patients and their caregivers about preventing oral infections with regular dental appointments and daily oral care.

Stress the importance of using fluoride to prevent dental caries associated with xerostomia.

DENTAL CARIES. Children and young adults who have Down

syndrome have fewer caries than people without this developmental disability. Several associated oral conditions may contribute to this fact: delayed eruption of primary and permanent teeth; missing permanent teeth; and small-sized teeth with wider spaces between them, which make it easier to remove plaque. Additionally, the diets of many children with Down syndrome are closely supervised to prevent obesity; this helps reduce consumption of cariogenic foods and beverages.

AUTISMA

Apakah autisma ini?

Kanak-kanak autisma biasanya dilabelkan

Bodoh,degil, berkelakuan pelik,tercicir dlm pelajaran

Buat perangai,tidak mengendahkan orang lain,ulang perkara yg sama, melakukan perkara yg boleh mencederakan diri

Apakah autisma?

Hidup dlm dunia tersendiriSeolah-olah pekakTidak bertutur/bertutur dgn cara yang

aneh Jarang tersenyumTidak pernah meminta utk didukung

STATISTIK

2-6 kes setiap 1,000 orang4:1-Lelaki:PerempuanLebih kerap dikalangan lelaki kulit putihDi Malaysia: 1:500 kanak-kanak Jumlah: 47,000 orangBerlaku sebelum kanak-kanak berusia 3

thn

AUTISMA

Gangguan perkembangan otakKecacatan neurologiMasalah dengan perhubungan

sosial,komunikasi dan emosiKurang kebolehan imaginasi

dan bermainTingkahlaku terhad dan

berulangBoleh dirawat tetapi tidak dpt

dipulihkan

APAKAH PENYEBAB AUTISMA?

Tidak pastiKedua-dua faktor genetik dan

persekitaranBeberapa kawasan otak yang tidak

sekataTahap serotonin atau neurotransmiter

lain di otakGangguan pertumbuhan otak diawal

perkembangan fetal

FAKTOR KETURUNAN Jika seorang kembar terlibat-90%

kembar kedua Seorang anak autisma-risiko anak

kedua 5% Ibu bapa dan saudara mara ada

menunjukkan gangguan didalam perhubungan sosial dan komunikasi

Manic depression-lebih kerap didalam keluarga autisma

Bolehkah Autisma sembuh? Tidak

Pengesanan awal,rawatan dan pendidikan boleh membantu mereka membesar dan belajar dgn baik

Pengesanan awal sangat penting

Ujian Saringan penting: eg: M-CHAT(Modified Checklist Autism In Toddlers)-soalan berkenaan perkembangan dan tingkah laku

PROGNOSIS

Ditentukan oleh kecerdasan otak (IQ) dan penguasaan bahasa pada usia 5 thn.

Baik jika IQ >60 dan penguasaan bahasa baik pada usia 5 thn

2/3 pesakit autisme-ketidakupayaan serius semasa dewasa

5-17%:boleh bekerja dengan sokonganKebanyakan: perhubungan sosial

abnormal

KOMPLIKASI

Peringkat awal kanak-kanak: Hiperaktif,panas baran

Peringkat akhir kanak-kanak: Suka menyerang,mencederakan diri sendiri

Peringkat remaja dan dewasa: Kemurungan dan epilepsi

MASALAH DENTAL DLM AUTISME DAMAGING ORAL HABITS are

common and include bruxism; tongue thrusting; self-injurious behavior such as picking at the gingiva or biting the lips; and pica--eating objects and substances such as gravel, cigarette butts, or pens.

It is presumed that children with Autism have a high threshold for pain, and what pain is much worse than a toothache. It is not an area that is easy to inspect and if the Autistic child has no speech as 50% of them do, then they may not have a way to tell you and may be in some considerable amount of pain for some time before you suspect anything is wrong.

DENTAL CARIES risk increases in patients who have a preference for soft, sticky, or sweet foods; damaging oral habits; and difficulty brushing and flossing.

PERIODONTAL DISEASE occurs in people with autism in much the same way it does in persons without developmental disabilities.

Some patients benefit from the daily use of antimicrobial agent such as chlorhexidine.

Stress the importance of conscientious oral hygiene and frequent prophylaxis.

Sometimes a visit before treatment is initiated is helpful for the child with Autism to get them used to the setting. Make sure that you are not stressed before or during the visit as the Autistic child seems to pick this up from you and will react accordingly.If you remain calm and positive throughout the visit, they are also likely to be more manageable.

TOOTH ERUPTION may be delayed due to phenytoin-induced gingival hyperplasia. Phenytoin is commonly prescribed for people with autism.

TRAUMA and INJURY to the mouth from falls or accidents occur in people with seizure disorders. Suggest a tooth saving kit for group homes. Emphasize to caregivers that traumas require immediate professional attention and explain the procedures to follow if a permanent tooth is knocked out. Also, instruct caregivers to locate any missing pieces of a fractured tooth, and explain that radiographs of the patient's chest may be necessary to determine whether any fragments have been aspirated.

CLEFT LIP AND PALATE

Orofacial clefts are birth defects in which there is an opening in the lip and/or palate (roof of the mouth) that is caused by incomplete development during early fetal formation.

Cleft lip and cleft palate are treatable. Most kids born with these can have surgery to repair these defects within the first 12-18 months of life.

Cleft lip-3-6 mths Cleft palate-6-9 mths

TYPES

CAUSES

Part of syndrome Genetic Medication-anti epileptic Cigarette smoke Lack of certain medications-folate

acid deficiency

Associated problems

Feeding difficulties Middle ear effusion Hearing loss Speech difficulties Dental abnormalities

DENTAL ABNORMALITIES

Small teeth, missing teeth, extra teeth (called supernumerary), or malpositioned teeth. They may have a defect in the gums or alveolar ridge (the bone that supports the teeth). Defects of the alveolar ridge can displace, tip, or rotate permanent teeth, or prevent permanent teeth from coming in properly.

TREATMENT geneticist pediatrician plastic surgeon ear, nose, and throat physician (otolaryngologist) oral surgeon orthodontist dentist speech-language pathologist audiologist nurse social worker psychologist team coordinator

KURANG UPAYA PENDENGARAN Tidak dapat mendengar dengan jelas di kedua-

dua telinga tanpa menggunakan alat bantuan pendengaran atau tidak dapat mendengar langsung walaupun dengan menggunakan alat bantuan pendengaran. Terdapat empat (4) tahap yang bolh dikategorikan sebagai OKU Pendengaran, iaitu:

Minumum (Mild) - (15 - <30 dB)   (Kanak-kanak)- (20 - <30 dB)   (Orang Dewasa)

Sederhana (Moderate) - (30 - <60 dB) Teruk (Severe) - (60 - <90 dB) Sengat Teruk (Profound) - (>90 dB)

TAHAP KECACATANNORMAL - Mengesan bunyi pada intensiti lebih daripada 25dB 

RINGAN - Mula mengesan bunyi antara 25dB hingga 40dB

SEDERHANA - Mula mengesan antara 41dB hingga 70dB

TERUK - Mengesan pada intensiti 71dB hingga 90dB

SANGAT TERUK - Mengesan pada intensiti 90dB ke atas

Mekanisma pendengaran

3 masalah kurang upaya pendengaran

Masalah pendengaran konduktif berlaku apabila terdapat masalah atau jangkitan pada telinga luar dan telinga tengah

Contoh masalah dan jangkitan yang boleh menyebabkan masalah pendengaran konduktif ialah ketiadaan lubang telinga (atresia), cuping telinga kecil atau tiada cuping telinga (mikrotia / anotia), sumbatan tahi telinga di salur telinga, jangkitan kuman pada salur telinga atau telinga tengah dan gegendang telinga bocor/pecah

PEMERIKSAAN TELINGA

Masalah pendengaran sensorineural pula berlaku apabila terdapat masalah atau jangkitan pada telinga dalam, tempat di mana koklea dan saraf pendengaran beradaMasalah ini tidak dapat dilihat secara fizikal (tiada rembesan nanah atau kecacatan fizikal) tetapi hanya dapat dikenalpasti melalui pemeriksaan pendengaran secara menyeluruh.Masalah ini tidak dapat dirawat, tidak seperti masalah pendengaran konduktif yang boleh dirawat secara pengambilan ubat atau pembedahan

Masalah pendengaran campuran pula berlaku apabila terdapat kehadiran kedua-dua masalah pendengaran serentak iaitu masalah pendengaran konduktif dan sensorineural hadir

Contohnya, seseorang yang mempunyai masalah pendengaran sensorineural juga mempunyai mampatan tahi telinga dikategorikan sebagai mempunyai masalah pendengaran campuran. Apa jua masalah yang berlaku di telinga luar/tengah beserta masalah di telinga dalam disebut sebagai masalah pendengaran campuran

KURANG UPAYA PENDENGARANCIRI-CIRI Meminta percakapan diulang berkali-kali Bercakap dengan nada suara yang lebih kuat daripada biasa Tidak memahami arahan yang diberikan atau silap

memahami arahan Sukar memahami perbualan di tempat bising Terpaksa memalingkan kepala ke arah sumber bunyi dalam

usaha untuk memahami apa yang didengari Sukar memahami perbualan telefon Toleransi terhadap bunyi bising berkurang Suka memencilkan diri dari bergaul dan berbual Terdedah kepada bunyi yang sangat kuat Terlibat dalam kemalangan yang melibatkan kecederaan di

bahagian kepala dan leher. Terdapat ahli keluarga yang juga mempunyai masalah

pendengaran Pengambilan ubat ototoksik (anti-histamin, anti-diuretik dll) Menghidap penyakit sistemik (kencing manis, hiperkolesterol,

buah pinggang dll)

PENYEBAB Sebelum Kelahiran Baka Pengambilan dadah,

alkohol Toksemia Jangkitan penyakit Tidak diketahui Semasa Kelahiran Tidak cukup bulan Kelahiran yg terlalu lama Sawan

Selepas Kelahiran Penyakit berjangkit

disebabkan bakteria dan virus

Kecederaan telinga Pengambilan ubat

berlebihan ototoksik (streptomycin)

Demam campak, beguk Jaundis Berat badan kurang

dari 1500g Jangkitan kuman telinga

tengah Tidak diketahui

PENGURUSANLangkah awal perlulah diambil dalam mengatasi

masalah pendengaran terutama di kalangan kanak-kanak. Ia boleh mendatangkan kesan buruk terhadap perkembangan bahasa dan pertuturan kanak-kanak tersebut. Ini seterusnya akan merencat perkembangan sosial, komunikasi, psikologi dan vokasional individu berkenaan. Masalah pendengaran perlu dikesan sejak kecil (umur < 3 bulan) agar pemasangan alat bantu dengar yang bersesuaian serta program rawatan seterusnya dapat dilakukan. Ini adalah bertujuan untuk mengurangkan kesan masalah pendengaran yang dihadapi oleh kanak-kanak berkenaan:

HEARING LOSS and DEAFNESS can also be accommodated with careful planning. Patients with a hearing problem may appear to be stubborn because of their seeming lack of response to a request.

Patients may want to adjust their hearing aids or turn them off, since the sound of some instruments may cause auditory discomfort.

If your patient reads lips, speak in a normal cadence and tone. If your patient uses a form of sign language, ask the interpreter to come to the appointment. Speak with this person in advance to discuss dental terms and your patient's needs.

Visual feedback is helpful. Maintain eye contact with your patient. Before talking, eliminate background noise (turn off the radio and the suction). Sometimes people with a hearing loss simply need you to speak clearly in a slightly louder voice than normal. Remember to remove your facemask first or wear a clear face shield.

KURANG UPAYA PENGLIHATAN Tidak dapat melihat atau mengalami penglihatan

terhad di kedua-dua belah mata walaupun dengan menggunakan alat bantu penglihatan seperti cermin mata atau kanta sentuh. Terdapat dua (2) tahap OKU Penglihatan, iaitu :

Buta (Blind) Penglihatan kurang daripada 3/60 atau medan

penglihatan kurang dari 10 darjah dari fixation.

Terhad (Low Vision / Partially Sighted) Penglihatan lebih teruk dari 6/18 tetapi sama dengan

atau lebih baik daripada 3/60 walaupun dengan menggunakan alat bantuan penglihatan atau medan penglihatan kurang dari 20 darjah dari fixation.

KURANG UPAYA PENGLIHATAN

Globally the major causes of visual impairment are:

uncorrected refractive errors (myopia, hyperopia or astigmatism), 43 %

cataract, 33% glaucoma, 2%.

Siapakah yg berisiko

People aged 50 and over About 65 % of all people who are visually

impaired are aged 50 and older.

Children below age 15 An estimated 19 million children are

visually impaired. Of these, 12 million children are visually impaired due to refractive errors, a condition that could be easily diagnosed and corrected. 1.4 million are irreversibly blind for the rest of their lives.

REFRACTIVE ERROR

A refractive error, or refraction error, is an error in the focusing of light by the eye and a frequent reason for reduced visual acuity.

Causes: Family history Genetic disorder-Marfan

syndrome

Down syndrome

ANATOMI MATA

Myopia: When the optics are too powerful for the length of the eyeball one has myopia or nearsightedness. This can arise from a cornea with too much curvature (refractive myopia) or an eyeball that is too long (axial myopia). Myopia can easily be corrected with a concave lens which causes the divergence of light rays before they reach the retina.(Rabun jauh)

Hyperopia: When the optics are too weak for the length of the eyeball, one has hyperopia or farsightedness. This can arise from a cornea with not enough curvature (refractive hyperopia) or an eyeball that is too short (axial hyperopia).This can be corrected with convex lenses which cause light rays to converge prior to hitting the retina.(Rabun dekat)

Myopia –Rabun jauh

Hyperopia –Rabun dekat

Astigmatism is a condition in which an abnormal curvature of the cornea can cause two focal points to fall in two different locations, making objects up close and at a distance appear blurry.

Treatment

Glasses

Contact lenses

Refractive surgery

TREATMENT-DENTAL RELATED Determine the level of assistance your patient requires to move safely through the dental office. Use your patients' other senses to connect with them, establish trust, and make treatment a good experience. Tactile feedback, such as a warm handshake, can make your patients feel comfortable. Face your patients when you speak and keep them apprised of each upcoming step, especially when water will be used. Rely on clear, descriptive language to explain procedures and demonstrate how equipment might feel and sound. Provide written instructions in large print Encourage independence in daily oral hygiene. Ask patients to show you how they brush, and follow up with specific recommendations on brushing methods or toothbrush adaptations. Involve your patients in hands-on demonstrations of brushing and flossing. Some patients cannot brush and floss independently due to impaired physical coordination or cognitive skills. Talk to their caregivers about daily oral hygiene. Do not assume that all caregivers know the basics; demonstrate proper brushing and flossing techniques. A power toothbrush or a floss holder can simplify oral care. Also, use

your experiences with each patient to demonstrate sitting or standing positions for the caregiver. Emphasize that a consistent approach to oral hygiene is important--caregivers should try to use the same location, timing, and positioning. Some patients benefit from the daily use of an antimicrobial agent such as chlorhexidine. Recommend an appropriate delivery method based on your patient's abilities. Rinsing, for example, may not work for a patient who has swallowing difficulties or one who cannot expectorate. Chlorhexidine applied using a spray bottle or

toothbrush is equally efficacious. If use of particular medications has led to gingival hyperplasia, emphasize the importance of daily oral hygiene and frequent professional cleanings. Tips for caregivers are available in the booklet Dental Care Every Day: A Caregiver's Guide, also part of this series. Back to Top DENTAL CARIES. People with intellectual disability develop caries at the same rate as the general population. The prevalence of untreated dental caries, however, is higher among people with intellectual disability, particularly those living in noninstitutional settings. Emphasize noncariogenic foods and beverages as snacks. Advise caregivers to avoid using sweets as incentives or rewards. Advise patients taking medicines that cause xerostomia to drink water often. Suggest sugar-free medicine if available and stress the importance of rinsing with water after dosing. Recommend preventive measures such as fluorides and sealants. Back to Top MALOCCLUSION. The prevalence of malocclusion in people with intellectual disability is similar to that found in the general population, except for those with coexisting conditions such as cerebral palsy or Down syndrome. A developmental disability in and of itself should not be perceived as a barrier to orthodontic treatment. The

ability of the patient or caregiver to maintain good daily oral hygiene is critical to the feasibility and success of treatment. Back to Top MISSING PERMANENT TEETH, DELAYED ERUPTION, and ENAMEL HYPOPLASIA are more common in people with intellectual disability and coexisting conditions than in people with intellectual disability alone. Examine a child by his or her first birthday and regularly thereafter to help identify unusual tooth formation and patterns of eruption. Consider using a panoramic radiograph to determine whether teeth are congenitally missing. Patients often find this technique less threatening than individual films. Take appropriate steps to reduce sensitivity and risk of caries in your patients with enamel hypoplasia. Back to Top DAMAGING ORAL HABITS are a problem for some people with intellectual disability. Common habits include bruxism; mouth breathing; tongue thrusting; self-injurious behavior such as picking at the gingiva or biting the lips; and pica, eating objects and substances such as gravel, cigarette butts, or pens. If a mouth guard can be

tolerated, prescribe one for patients who have problems with self-injurious behavior or bruxism. Back to Top TRAUMA and INJURY to the mouth from falls or accidents occur in people with intellectual disability. Suggest a tooth-saving kit for group homes. Emphasize to caregivers that traumas require immediate professional attention and explain the procedures to follow if a permanent tooth is knocked out. Also, instruct caregivers to locate

any missing pieces of a fractured tooth, and explain that radiographs of the patient's chest may be necessary to determine whether any fragments have been aspirated. Physical abuse often presents as oral trauma. Abuse is reported more frequently in people with developmental disabilities than in the general population. If you suspect that a child is being abused or neglected, State laws require that you call your Child Protective Services agency. Assistance is also available from the Childhelp®

National Child Abuse Hotline at (800) 422-4453 or the Child Welfare Information Gateway (http://www.childwelfare.gov/).

Back to Top Making a difference in the oral health of a person with intellectual disability may go slowly at first, but determination can bring positive results--and invaluable rewards. By adopting the strategies discussed in this booklet, you can have a significant impact not only on your patients' oral health, but

on their quality of life as well.  Additional Readings Batshaw ML, Shapiro B, Farber MLZ.  Developmental Delay & Intellectual Disability. In Batshaw ML, Pellegrino L, Roizen NJ (eds.). Children With Disabilities (6th ed.). Baltimore, MD: Paul H. Brookes Publishing Co., 2007. Horwitz SM, Kerker BD, Owens PL, Zigler E. Dental health among individuals with mental retardation. In The Health Status and Needs of Individuals With Mental Retardation. New Haven, CT: Yale University School of Medicine, 2000. pp. 119-134. U.S. Public Health Service. Closing the Gap: A National Blueprint for Improving the Health of Individuals With Mental Retardation. Report of the Surgeon General's Conference on Health Disparities and Mental Retardation. Washington, DC, February 2001. Weddell JA, Sanders BJ, Jones JE. Dental problems of children with disabilities. In McDonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent (8th ed.). St. Louis, MO: Mosby, 2004. pp. 524-556. Back to Top For more information about intellectual disability, contact

National Institute of Child Health and Human DevelopmentInformation Resource Center P.O. Box 3006Bethesda, MD 20827(800) 370-2943http://www.nichd.nih.gov/ NICHDIRC@mail.nih.gov

ACKNOWLEDGMENTS  The National Institute of Dental and Craniofacial Research thanks the oral health professionals and caregivers who contributed their time and expertise to reviewing and pretesting the Practical Oral Care series.

Expert Review Panel Mae Chin, RDH, University of Washington, Seattle, WA Sanford J. Fenton, DDS, University of Texas, Houston, TX Ray Lyons, DDS, New Mexico Department of Health, Albuquerque, NM Christine Miller, RDH, University of the Pacific, San Francisco, CA Steven P. Perlman, DDS, Special Olympics Special Smiles, Lynn, MA David Tesini, DMD, Natick, MA This booklet is one in a series on providing oral care for people with mild or moderate developmental disabilities. The issues and care strategies listed are intended to provide general guidance on how to manage various oral health challenges common in people with intellectual disability. Other booklets in this series:

Continuing Education: Practical Oral Care for People With Developmental Disabilities Practical Oral Care for People With Autism Practical Oral Care for People With Cerebral Palsy Practical Oral Care for People With Down Syndrome Wheelchair Transfer: A Health Care Provider's Guide Dental Care Every Day: A Caregiver's Guide    Back to Top   This publication is not copyrighted.  Make as many photocopies as you need.

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KETIDAKUPAYAAN MENTAL Keadaan penyakit mental yang teruk yang telah

diberi rawatan atau telah diberi diagnosis selama sekurang-kurangnya dua (2) tahun oleh Pakar Psikiatri. Akibat daripada penyakit yang dialami dan telah menjalani rawatan psikiatri, mereka masih tidak berupaya untuk berfungsi sama ada sebahagian atau sepenuhnya dalam hal berkaitan dirinya atau perhubungan dalam masyarakat. Di antara jenis-jenis penyakit mental tersebut ialah Organic Mental Disorder yang serius dan kronik, Skizofrenia, Paranoid, Mood Disorder (depression, bipolar) dan Psychotic Disorder seperti Schizoaffective Disorder dan Persistent Delusional Disorders.

Apakah penyakit skizofrenia? Major psychiatric disorder

Mengubah cara persepsi,pemikiran dan tingkahlaku

Mengganggu otak dlm proses penerimaan dan penafsiran maklumat

FAKTOR RISIKO Sejarah keluarga skizofrenia-Parents-6%-Siblings-9%-Children-13%-Dizygotic twin (Kembar tak seiras)-17%-Children with 2 affected parents-46%-Monozygotic twin-48%

FAKTOR RISIKO Sejarah komplikasi obstetrik Cannabis abusers Offspring of older fathers Unmarried mothers Childhood CNS infection

GEJALA-GEJALA POSITIF

Delusi Halusinasi Pertuturan/pemikiran yang tidak

teratur Tingkahlaku tidak teratur Tingkahlaku katatonik

GEJALA-GEJALA NEGATIFKekurangan motivasi dan tenaga

Affective flattening-kurang ekspresi emosi-ekspresi muka,ton

suara,sentuhan mata dan bahasa badan

Alogia (poverty of speech)-kurang kelancaran pertuturan (pemikiran tersangkut)

Avolition-tidak berminat utk keluar bersiar-siar,tidak berminat

pada perkara yg sebelum ini diminati,duduk didalam rumah tanpa melakukan sesuatu berjam-jam

GEJALA KOGNITIF Masalah dalam proses pemikiran-

masalah pembelajaran dan daya penumpuan

Pemikiran tidak teratur/bercelaru Pemikiran lembap Susah utk faham Kurang daya penumpuan Kurang daya ingatan Sukar utk mengeluarkan idea Sukar utk sepadukan

pemikiran,perasaan dan tingkahlaku

RAWATAN

Ubat-ubatan Pendidikan

(Psychoeducation) Kaunseling dan

psikoterapi Rehabilitasi (pemulihan) Kumpulan sokongan Perawatan dalam

komuniti

MASALAH DENTAL IN MENTAL CHALLENGE

People with intellectual disability have poorer oral health and oral hygiene than those without this condition. Data indicate that people who have intellectual disability have more untreated caries and a higher prevalence of gingivitis and other periodontal diseases than the general population.

PENGURUSAN MASALAH DENTAL Set the stage for a successful visit by involving the entire dental

team--from the receptionist's friendly greeting to the caring attitude of the dental assistant in the operatory. All should be aware of your patient's mental challenges.

Reduce distractions in the operatory, such as unnecessary sights, sounds, or other stimuli, to compensate for the short attention spans commonly observed in people with intellectual disability.

Talk with the parent or caregiver to determine your patient's intellectual and functional abilities, then explain each procedure at a level the patient can understand. Allow extra time to explain oral health issues or instructions and demonstrate the instruments you will use.

Address your patient directly and with respect to establish a rapport. Even if the caregiver is in the room, direct all questions and comments to your patient.

PENGURUSAN MASALAH DENTAL Use simple, concrete instructions and repeat them often to

compensate for any short-term memory problems. Speak slowly and give only one direction at a time. Be consistent in all aspects of oral care, since long-term memory is usually unaffected.

Use the same staff and dental operatory each time to help sustain familiarity. The more consistency you provide for your patients, the more likely they will cooperate.

Listen actively, since communicating clearly is often difficult for people with intellectual disability. Show your patient whether you understand. Be sensitive to the methods he or she uses to communicate, including gestures and verbal or nonverbal requests.

TERIMA KASIH