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Developmental disabilities such as autism, cerebral palsy, Down syndrome, and mental
retardation are present during childhood or adolescence and last a lifetime. They
affect the mind, the body, and the skills people use in everyday life: thinking, talking,
and self-care. People with disabilities often need extra help to achieve and maintain
good health. Oral health is no exception.
Over the past three decades, a trend toward deinstitutionalization has brought people
of all ages and levels of disability into the fabric of our communities. Today, approximately
80 percent of those with developmental disabilities are living in community-based
group residences or at home with their families. People with disabilities and their
caregivers now look to providers in the community for dental services.
Providing oral care to patients with developmental disabilities requires adaptation
of the skills you use every day. In fact, most people with mild or moderate developmental
disabilities can be treated successfully in the general practice setting. This booklet
presents an overview of physical, mental, and behavioral challenges common in these
patients and offers strategies for providing oral care.
Health Challenges and Strategies for Care
Before the appointment, obtain and review the patient's medical history. Consultation
with physicians, family, and caregivers is essential to assembling an accurate medical
history. Also, determine who can legally provide informed consent for treatment.
MENTAL CAPABILITIES vary in people with developmental disabilities
and influence how well they can follow directions in the operatory and at home.
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Determine each patient's mental capabilities and communication skills. Talk with caregivers
about how the patient's abilities might affect oral health care. Be receptive to their
thoughts and ideas on how to make the experience a success.
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Allow time to introduce concepts in language that patients can understand.
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Communicate respectfully with your patients and comfort those who resist dental care.
Repeat instructions when necessary and involve your patients in hands-on demonstrations.
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BEHAVIOR PROBLEMS can complicate oral health care. Anxiety
and fear about dental treatment can cause some patients to be uncooperative. Behaviors
may range from fidgeting or temper tantrums to violent, self-injurious behavior such
as head banging. This is challenging for everyone, but the following strategies can
help reduce behavior problems:
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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.
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Arrange for a desensitizing appointment to help the patient become familiar with the
office, staff, and equipment before treatment begins.
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Try to gain cooperation in the least restrictive manner. Some patients' behavior may
improve if they bring comfort items such as a stuffed animal or a blanket. Asking
the caregiver to sit nearby or hold the patient's hand may be helpful as well.
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Make appointments short whenever possible, providing only the treatment that the patient
can tolerate. Praise and reinforce good behavior and try to end each appointment on
a good note.
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Use immobilization techniques only when absolutely necessary to protect the patient
and staff during dental treatment--not as a convenience. There are no universal guidelines
on immobilization that apply to all treatment settings. Before employing any kind
of immobilization, it may help to consult available guidelines on federally funded
care, your State department of mental retardation/mental health, and your State Dental
Practice Act. Guidelines on behavior management published by the American Academy
of Pediatric Dentistry (www.aapd.org) may also be
useful. Obtain consent from your patient's legal guardian and choose the least restrictive
technique that will allow you to provide care safely. Immobilization should not cause
physical injury or undue discomfort.
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MOBILITY PROBLEMS are a concern for many people with disabilities;
some rely on a wheelchair or a walker to move around.
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Positioning for treating a patient in a wheelchair. Note the
support a sliding board can provide. Sliding or transfer boards are available from
home health care companies. |
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Observe the physical impact a disability has and how a particular patient moves. Look
for challenges such as uncontrolled body movements or concerns about posture.
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Maintain a clear path for movement throughout the treatment setting.
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If you need to transfer your patient from a wheelchair to the dental chair, ask the
patient or caregiver about special preferences such as padding, pillows, or other
things you can provide. Often the patient or caregiver can explain how to make a smooth
transfer.
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Certain patients cannot be moved into the dental chair but instead must be treated
in their wheelchairs. Some wheelchairs recline or are specially molded to fit people's
bodies. Lock the wheels, then slip a sliding board (also called a transfer board)
behind the patient's back to support the head and neck.
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NEUROMUSCULAR PROBLEMS can affect the mouth. Some people with
disabilities have persistently rigid or loose masticatory muscles. Others have drooling,
gagging, and swallowing problems that complicate oral care.
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If a patient has a gagging problem, schedule an early morning appointment, before
eating or drinking. Help minimize the gag reflex by placing your patient's chin in
a neutral or downward position.
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If your patient has swallowing problems, tilt the head slightly to one side and place
his or her body in a more upright position.
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If you use local anesthesia, be sure your patient does not chew the tongue or cheek.
A short-lasting form of anesthesia may work well.
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UNCONTROLLED BODY MOVEMENTS can jeopardize safety and your
ability to deliver dental care. Pay special attention to the following:
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Treatment setting: Make the treatment setting calm and supportive. Place
dental instruments behind the patient and carefully position other objects such as
cords and the light above the dental chair.
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Patient's position: Determine in advance whether a patient will need
to be treated in his or her wheelchair. If not, keep the patient in the center of
the dental chair. Pillows can help maintain a comfortable position.
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Your position: Observe the patient's movements and look for patterns
to help anticipate direction. Place yourself behind the patient and gently cradle
the head to provide support. Rest your hand around the mandible. (See the illustration above.)
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CARDIAC DISORDERS can affect the delivery of oral health care.
Many people with Down syndrome, for example, have congenital heart disorders that
place them at risk for bacterial endocarditis. Prescribe antibiotic prophylaxis when
indicated (www.americanheart.org). Contact
your patient's primary care physician if you have questions about the medical history.
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GASTROESOPHAGEAL REFLUX sometimes affects people with central
nervous system disorders such as cerebral palsy. Teeth may be sensitive or display
signs of erosion. Consult your patient's physician about the management of reflux.
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Place patients in a slightly upright position for treatment.
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Talk with patients and caregivers about rinsing with plain water or a water and baking
soda solution. Doing so at least four times a day can help mitigate the effects of
gastric acid. Stress that using a fluoride gel, rinse, or toothpaste every day is
essential.
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SEIZURES accompany many developmental disabilities. The mouth
is always at risk during a seizure: Patients may chip teeth or bite the tongue or
cheeks. Persons with controlled seizure disorders can easily be treated in the general
dental office.
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Consult your patient's physician. Record information in the chart about the frequency
of seizures and the medications used to control them. Determine before the appointment
whether medications have been taken as directed. Know and avoid any factors that trigger
your patient's seizures.
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Be prepared to manage a seizure. If one occurs during oral care, remove any instruments
from the mouth and clear the area around the dental chair. Attaching dental floss
to rubber dam clamps and mouth props when treatment begins can help you remove them
quickly. Do not attempt to insert any objects between the teeth during a seizure.
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Stay with your patient, turn him or her to one side, and monitor the airway to reduce
the risk of aspiration.
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VISUAL IMPAIRMENTS affect many people with developmental disabilities.
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Determine the level of assistance your patient requires to move safely through the
office.
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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.
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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 (16 point or larger).
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HEARING LOSS and DEAFNESS sometimes occur in people with developmental
disabilities.
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Patients may want to adjust their hearing aids or turn them off, since the sound of
some instruments may cause auditory discomfort.
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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.
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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.
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LATEX ALLERGIES can be a serious problem. People who have
spina bifida or who have had frequent surgeries are especially prone to developing
an allergic reaction or a sensitivity to latex. An allergic reaction can be life threatening.
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Ask patients and caregivers about the presence of a latex allergy before you begin
treatment.
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Schedule appointments for your latex-allergic or -sensitive patients at the beginning
of the day when there are fewer airborne allergens circulating through the office.
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Use latex-free gloves and equipment and keep an emergency medical kit handy.
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Record in the patient's chart strategies that were successful in providing care. Note
your patient's preferences and other unique details that will facilitate treatment,
such as music, comfort items, and flavor choices.
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Oral Health Problems and Strategies for Care
People with developmental disabilities typically have more oral health problems than
the general population. Focusing on each person's specific needs is the first step
toward achieving better oral health.
DENTAL CARIES is common in people with developmental disabilities.
In addition to discussing the problems associated with diet and oral hygiene, caution
patients and caregivers about the cariogenic nature of prolonged bottle feeding and
the adverse side effects of certain medications.
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Recommend preventive measures such as fluorides and sealants.
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Caution patients or their caregivers about medicines that reduce saliva or contain
sugar. Suggest that patients drink water frequently, take sugar-free medicines when
available, and rinse with water after taking any medicine.
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Advise caregivers to offer alternatives to cariogenic foods and beverages as incentives
or rewards.
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Educate caregivers about preventing early childhood caries.
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Encourage independence in daily oral hygiene. Ask patients to show you how they brush,
and follow up with specific recommendations. Perform hands-on demonstrations to show
patients the best way to clean their teeth.
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If necessary, adapt a toothbrush to make it easier to hold. For example, place a tennis
ball or bicycle grip on the handle, wrap the handle in tape, or bend the handle by
softening it under hot water. Explain that floss holders and power toothbrushes are
also helpful.
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Some patients cannot brush and floss independently. Talk to caregivers about daily
oral hygiene and do not assume that they know the basics. Use your experiences with
each patient to demonstrate oral care techniques and 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.
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PERIODONTAL DISEASE occurs more often and at a younger age
in people with developmental disabilities. Contributing factors include poor oral
hygiene, damaging oral habits, and physical or mental disabilities. Gingival hyperplasia
caused by medications such as some anticonvulsants, antihypertensives, and immunosuppressants
also increases the risk for periodontal disease.
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Some patients benefit from the daily use of an antimicrobial agent such as chlorhexidine.
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Stress the importance of conscientious oral hygiene and frequent prophylaxis.
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MALOCCLUSION occurs in many people with developmental disabilities
and may be associated with intraoral and perioral muscular abnormalities, delayed
tooth eruption, underdevelopment of the maxilla, and oral habits such as bruxism and
tongue thrusting. Malocclusion can make chewing and speaking difficult and increase
the risk of periodontal disease, dental caries, and oral trauma. Orthodontic treatment
may not be an option for many, but a developmental disability in and of itself should
not be perceived as a barrier to orthodontic care. The ability of the patient or the
caregiver to maintain good daily oral hygiene is critical to the feasibility and success
of orthodontic treatment.
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DAMAGING ORAL HABITS can be a problem for people with developmental
disabilities. Some of the most common of these habits are bruxism, food pouching,
mouth breathing, and tongue thrusting. Other oral habits include self-injurious behavior
such as picking at the gingiva or biting the lips; rumination, where food is chewed,
regurgitated, and swallowed again; and pica, eating objects and substances such as
gravel, sand, cigarette butts, or pens.
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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 foam applicator
swab.
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If a mouth guard can be tolerated, prescribe one for patients who have problems with
self-injurious behavior or bruxism.
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ORAL MALFORMATIONS affect many people with developmental disabilities.
Patients may present with enamel defects, high lip lines with dry gingiva, and variations
in the number, size, and shape of teeth. Craniofacial anomalies such as facial asymmetry
and hypoplasia of the midfacial region are also seen in this population. Identify
any malformations and explain to the caregiver the implications for daily oral hygiene
and future treatment planning.
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TOOTH ERUPTION may be delayed in children with developmental
disabilities. Eruption times are different for each child, and some children may not
get their first primary tooth until they are 2 years old. Delays are often characteristic
of certain disabilities such as Down syndrome. In other cases, eruption problems are
attributable to the gingival hyperplasia that can result from medications such as
phenytoin and cyclosporin. Dental examination by a child's first birthday and regularly
thereafter can help identify atypical patterns of eruption.
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TRAUMA and INJURY to the mouth from falls or accidents occur
in people with seizure disorders or cerebral palsy. 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® USA National
Child Abuse Hotline at (800) 422-4453 or the National Clearinghouse on Child Abuse
and Neglect Information (nccanch.acf.hhs.gov).
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Making a difference in the oral health of a person with a developmental 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. Children With Disabilities (5th ed.). Baltimore, MD: Paul H. Brookes
Publishing Co., 2002.
Fenton SJ, Perlman S, Turner H, eds. Oral Health Care for People With Special Needs:
Guidelines for Comprehensive Care. River Edge, NJ: Exceptional Parent, Psy-Ed
Corp., 2003.
Hannequin M, Veyrune J-L. Significance of oral health in persons with Down syndrome:
a literature review. Developmental Medicine and Child Neurology, 41:275-283,
1999.
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.
Klein U, Nowak AJ. Characteristics of patients with autistic disorder (AD) presenting
for dental treatment: a survey and chart review. Special Care in Dentistry, 19(5):200-207,
1999.
McDonald RE, Avery DR. Dentistry for the Child and Adolescent (7th ed.). St.
Louis, MO: Mosby, 2000.
Southern Association of Institutional Dentists (SAID). A Self-Study Course for
Dental Professionals at Institutions Serving People With Mental and Physical Disabilities. SAID,
1994 with periodic updates. Available at www.saiddent.org.
Accessed April 2004.
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.
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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 developmental disabilities.
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Other booklets in this series:
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Practical Oral Care for People With Autism
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Practical Oral Care for People With Cerebral Palsy
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Practical Oral Care for People With Down Syndrome
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Practical Oral Care for People With Mental Retardation
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Wheelchair Transfer: A Health Care Provider's Guide
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Dental Care Every Day: A Caregiver's Guide
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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
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Mae Chin, RDH, University of Washington, Seattle, WA
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Sanford J. Fenton, DDS, University of Tennessee, Memphis, TN
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Ray Lyons, DDS, New Mexico Department of Health, Los Lunas, NM
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Christine Miller, RDH, University of the Pacific, San Francisco, CA
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Steven P. Perlman, DDS, Special Olympics Special Smiles, Lynn, MA
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David Tesini, DMD, Natick, MA
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For additional copies of this booklet, contact
National Institute of Dental and Craniofacial Research
National Oral Health Information Clearinghouse
1 NOHIC Way
Bethesda, MD 20892-3500
(301) 402-7364
www.nidcr.nih.gov
nohic@nidcr.nih.gov
This publication is not copyrighted.
Make as many photocopies as you need.
NIH Publication No. 04-5196
Printed May 2004
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