A Practical Approach to Special Care in Dentistry. Группа авторов

(ideally in Braille for those patients who have complete blindness) Consent/capacity Patients of legal age can generally sign the informed consent personallyIt is essential that this form be printed in sufficiently large type or even have a Braille versionIf the patient cannot read, a close family member/friend acting as a witness can read it for them (in some countries, the presence of this witness is mandatory) Anaesthesia/sedation Local anaesthesiaSome patients have poor pain tolerance (increased tactile sensitivity)SedationIn the event of glaucoma, benzodiazepines should not be employed to induce conscious sedationGeneral anaesthesiaFor patients with glaucoma who require general anaesthesia, avoid using atropine Dental treatment BeforeConsider the use of audio aids which the patient can access at home to remind them of the planned treatmentAllow the patient to touch the chair and equipmentExplain all the dental procedures that will be performedThe ‘tell–feel (physical contact)–do’ technique can be usefulBefore planning rehabilitation with a removable prosthesis, ensure that the patient is sufficiently able to recognise, insert and remove the prosthesisWhen planning for prostheses, consider that some patients with visual deficit do not tolerate muco‐supported prostheses wellFor selected patients, orthodontic treatments can be performed (including multibracket appliances) to improve function and aesthetics if this is a concernDuringWarn the patient if you need to leave the dental office and when you will returnThroughout the procedure, warn the patient of each manoeuvre that will be performed, explaining in advance anticipated contact, noise, vibration and lightExercise particular caution with rotary instrumentation and injectionsReinforce positive behavioursAfterThe success of fixed prostheses can be affected by poor oral hygieneReinforce positive behavioursPostoperative instructions should be written in large font (ideally in Braille for complete blindness) or provided in an audio format Drug prescription For patients with glaucoma, anticholinergic agents (such as atropine, scopolamine and glycopyrrolate, which are prescribed to control drooling), carbamazepine, diazepam, corticosteroids and tricyclic antidepressants are contraindicated Education/prevention Audio, tactile and supervised training techniques and instructions in Braille are useful for improving the oral hygiene of those with visual deficits (whose motivation is usually magnified)These modified approaches to educational programmes on oral health promotion have demonstrable efficacyElectric toothbrushes can be more effective than manual toothbrushes as long as the vibration is tolerated

Figure 3.1.3 Orthodontic treatment for a patient with visual impairment.

      Aetiopathogenesis

       In industrialised countries, the main causes of visual deficit among adults are age‐related macular degeneration, glaucoma and diabetic retinopathy; paediatric blindness is mainly due to retinopathy of prematurity

       In developing countries, the most common causes are cataracts and trachoma; in children, congenital cataracts appear frequently in the context of a polymalformative syndrome (a recognisable pattern of congenital anomalies that are known or thought to be causally related)

      Clinical Presentation

       The clinical manifestations depend on the location of the injury causing the visual impairment (e.g. optic nerve injuries are usually irreversible) and its aetiology (e.g. congenital cataracts can be associated with epilepsy)

       The most suggestive symptoms of visual deficit include the following:Visual adaptation problems in dark settingsDifficulty focusing on near or distant objectsExcessive light sensitivityEye redness or inflammationSudden eye painDouble visionSudden vision loss in one eyeOnset of a dark spot in the centre of the visual fieldLoss of peripheral visionSudden blurred vision

      Diagnosis

       Visual acuity tests include the Snellen test (ability to perceive the forms of objects and to distinguish their details)

       Visual field and peripheral vision tests (ability to perceive objects placed outside the central vision area)

       Ophthalmoscopy/fundoscopy (retinal examination)

       Other: e.g. tonometry, slit‐lamp, photometers

      Management

       Cataract surgery

       Prescription glasses for correcting refractive errors

       Drugs for age‐related macular degeneration

       Support measures include braille (a tactile reading and writing system), electronic methods for identifying colour and, in extreme cases, guide dogs (Figures 3.1.4 and 3.1.5)

       There is speculation as to the future possibility of curing blindness with stem cells

      Prognosis

       Life expectancy can be affected by the coexistence of an underlying disease (e.g. polymalformative syndromes, diabetes)Figure 3.1.4 Braille is a useful communication tool mainly for complete blindness patients.Figure 3.1.5 When the blind patient uses a guide dog, avoid interfering with the dog.

      A World/Transcultural View

       About 75% of the population with visual deficits live in the poorest regions of Asia and Africa

       Among the lowest income countries, the proportion of children with blindness but caries free ranges from 53.2% in Sudan to 1.5% in India; paradoxically, studies in India have confirmed the efficacy of various preventive programmes based on promoting adapted oral hygiene techniques

Recommended Reading

      1 GBD 2019 Blindness and Vision Impairment Collaborators; Vision Loss Expert Group of the Global Burden of Disease Study (2020). Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the right to sight: an analysis for the global burden of disease study. Lancet Glob. Health: S2214‐109X(20)30489‐7.

      2 Hidaka, R., Furuya, J., Suzuki, H. et al. (2020). Survey on the oral health status of community‐dwelling older people with visual impairment. Spec. Care Dentist. 40: 192–197.

      3 Jain, A., Gupta, J., Aggarwal, V., and Goyal, C. (2013). To evaluate the comparative status of oral health practices, oral hygiene and periodontal status amongst visually impaired and sighted students. Spec. Care Dentist. 33: 78–84.

      4 Lee, S.Y. and Mesfin, F.B. (2020). Blindness. www.statpearls.com/

      5 Schembri,