As a new hygiene graduate, you’ll see patients from young to old and all ages in between. Treating a variety of patients, whether in a general or specialty practice, is one of the high points of clinical practice, and as clinical hygienists, we have the ability to transform smiles and lives. With our youngest patients, we may be able to help prevent frustration as they learn to communicate. Recognizing the signs of a developmental speech or motor delay and referring to the appropriate providers reinforces our importance as health professionals.
Understanding the difference between a delay or disorder is important for determining the appropriate referral resource. Understand that we are not diagnosing any developmental condition, simply recognizing the possibility of one. A developmental delay means a child’s skills are developing slower than normal. Every child is unique and achieves milestones at various stages, but there are some that need to be met within certain time frames. For example, by 12 months of age a child should be saying mama and dada.
Often, children who experience delays were born prematurely, have frequent ear infections, or have spent time in neonatal intensive care units, but they often catch up with their counterparts over time. Delays can be seen in language or communication, fine or gross motor skills, cognitive issues, and social, emotional, or self-care skills.
On the other hand, children who exhibit a developmental disorder have a skill, but the skill develops abnormally or does not develop at all. For example, a child using age-appropriate words or movements may suddenly stop or not progress to the next stage. Whether the child has a delay or disorder, they will be treated by a variety of health-care professionals, ranging from physical, occupational, and speech therapists, to social workers and physicians.
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Our focus is on the oral cavity, therefore, we can recognize speech and communication delays as part of our overall evaluation of a child. As the American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommends, children should be seen in a dental practice by their first birthday, preferably once the first teeth erupt or anytime between six and 12 months.
Since it may be difficult to do a “prophy” on a one-year-old, the dental visit can be more of an educational meeting with the parent or caregiver to reinforce good oral habits. Reviewing basic oral hygiene instruction (wiping the child’s mouth with a cloth or beginner brushing), nighttime bottle use, and pacifier or thumb sucking issues can be discussed during the first dental visit. Since early childhood caries is prevalent in many low-income communities, it is important to review homecare and the role sugar plays in the caries process. Providing the parent or caregiver with information about dental trauma as the child explores his or her environment is also a useful component of the first dental visit. The initial exam can be performed while the child is on the parent’s lap or in the dental chair.
The role of musculature
The oral cavity and various musculature of the head and neck are critical in the communication process and can be reviewed during the initial visit. Delayed motor skills are often evident in the oral musculature. For example, how long the infant or young child takes in nutrition—whether milk or solid food—can be an indicator of muscle discrepancies. Speech and its various language components can be affected by the movement of the lips, tongue, cheeks, and mandible. If muscle imbalances appear, such as a tight lingual frenum, speech production may be hindered. Some children display mouth breathing, sleep apnea issues, or oral sensitivity that can been seen in the oral cavity.
Here are questions that can be added to a pediatric medical history form to help recognize delays. With the advent of digital dental records, ask your practice management software company if they can create a customized medical history form that includes some of these questions.
- Does the child provide inappropriate answers to questions?
- Does the child speak in simple phrases by age two?
- Can others outside the family understand the child when they speak?
- Does the child tend to stuff food in their mouth? (This is for older children.)
- Does the child exhibit underdeveloped play skills for their age or have frequent bedwetting beyond age-appropriateness?
- Was the child born prematurely, spend time in NICU, or have frequent ear infections?
- Does the child hit or lash out when not able to communicate wants and needs?
Resources and state rules
For children from birth to age three or five, the local or state early intervention (EI) program is an excellent resource. Depending on a state’s rules and regulations regarding eligibility, all children can be screened for EI, but not all children may qualify. Depending on the state’s requirements, the criterion for EI varies from the family’s socioeconomic status and situation to the child’s medical history.
For example, the child of a teenage mother may receive EI services, while the child in a traditional family environment may not receive services even if the child’s delay is the same. Once a child reaches the age of EI majority, which is three or five depending on state rules, they can continue to receive services through the local school special education department (SPED). EI services are family-focused, with a family educational plan (FEP), while SPED is student-focused with an individual educational plan (IEP). Whether FEP or IEP, the goal is to provide services to eliminate or minimize the effects of the delay or disorder on the child.
A child that displays a delay can be treated by a myofunctional therapist, a dental sleep therapist, or an oral surgeon, depending on the diagnosis. The CDT code D0145—oral evaluation of patient under three years of age with counseling of primary caregiver—can be used for billing purposes, although it may or may not be covered by dental benefit plans. Since many EI or SPED programs do not have dental professionals on their teams, becoming a resource for your local program can enhance your practice’s community visibility. As a hygienist, you can volunteer to provide classes on early childhood dental care to your local programs.
Parents and caregivers of young children with a delay or disorder may become defensive about their child, so never interrogate a parent or caregiver about a child’s condition. Let them guide the conversation after you ask if they have any concerns, both dental or nondental, about their child. The questions on the medical history form can also open communication in a nonthreatening way. If a parent or caregiver responds favorably, let them know about the resources available, which provides reassurance and guidance that you’re caring for them and their child.
Recognizing the signs and symptoms of early childhood developmental delays or disorders can help alleviate the concern and frustration some families experience. Providing appropriate referrals is a step toward improving dental and medical collaboration.