Providing oral care to people with mental retardation requires adaptation of the skills
you use every day. In fact, most people with mild or moderate mental retardation can
be treated successfully in the general practice setting. This booklet will help you
make a difference in the lives of people who need professional oral care.
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Mental retardation is a disorder of intellectual and adaptive functioning, meaning
that people who are affected are challenged by the skills they use in everyday life.
Mental retardation is not a disease or a mental illness; it is a developmental disability
that varies in severity and is usually associated with physical problems. While one
person with mental retardation may have slight difficulty thinking and communicating,
another may face major challenges with basic self-care and physical mobility.
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Data indicate that people with mental retardation have more untreated caries and a
higher prevalence of gingivitis and other periodontal diseases than the general population.
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Health Challenges in Mental Retardation and Strategies for Care
Many people with mental retardation also have other disabilities such as cerebral
palsy, seizure or psychiatric disorders, attention deficit/hyperactivity disorder,
or problems with vision, communication, and eating. Though language and communication
problems are common in anyone with mental retardation, motor skills are typically
more affected when a person has coexisting conditions.
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 CHALLENGES. People with mental retardation learn slowly
and often with difficulty. Ordinary activities of daily living, such as brushing teeth
and getting dressed, and understanding the behavior of others as well as their own,
can all present challenges to a person with mental retardation.
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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. All should be aware of your patient's mental challenges.
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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
mental retardation.
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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.
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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.
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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.
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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.
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Listen actively, since communicating clearly is often difficult for people with mental
retardation. Show your patient whether you understand. Be sensitive to the methods
he or she uses to communicate, including gestures and verbal or nonverbal requests.
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BEHAVIOR CHALLENGES. While most people with mental retardation
do not pose significant behavior problems that complicate oral care, anxiety about
dental treatment occurs frequently. People unfamiliar with a dental office and its
equipment and instruments may exhibit fear. Some react to fear with uncooperative
behavior, such as crying, wiggling, kicking, aggressive language, or anything that
will help them avoid treatment. You can make oral health care a better experience
by comforting your patients and acknowledging their anxiety.
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Talk to the caregiver or physician about techniques they have found to be effective
in managing the patient's behavior.
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Schedule patients with mental retardation early in the day if possible. Early appointments
can help ensure that everyone is alert and attentive and that waiting time is reduced.
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Keep appointments short and postpone difficult procedures until after your patient
is familiar with you and your staff.
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Allow extra time for your patients to get comfortable with you, your office, and the
entire oral health care team. Invite patients and their families to visit your office
before beginning treatment.
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Permit the parents or caregiver to come into the treatment setting to provide familiarity,
help with communication, and offer a calming influence by holding your patient's hand
during treatment. Some patients' behavior may improve if they bring comfort items
such as a stuffed animal or blanket.
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Reward cooperative behavior with compliments throughout the appointment.
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Consider nitrous oxide/oxygen sedation to reduce anxiety and fear and improve cooperation.
Obtain informed consent from the legal guardian before administering any kind of sedation.
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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.
People with mental retardation often engage in perseveration, a continuous, meaningless
repetition of words, phrases, or movements. Your patient may mimic the sound of the
suction, for example, or repeat an instruction over and again. Avoid demonstrating
dental equipment if it triggers perseveration, and note this in the patient's record.
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PHYSICAL CHALLENGES. Mental retardation does not always include
a specific physical trait, although many people have distinguishing features such
as orofacial abnormalities, scoliosis, unsteady gait, or hypotonia due to coexisting
conditions. Countering physical challenges requires attention to detail.
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Maintain clear paths for movement throughout the treatment setting. Keep instruments
and equipment out of the patient's way.
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Place and maintain your patient in the center of the dental chair to minimize the
risk of injury. Placing pillows on both sides of the patient can provide stability.
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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 to ease the transition. The patient or caregiver can often
explain how to make a smooth transfer. (See Wheelchair Transfer: A Health Care
Provider's Guide, also part of this series.)
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Some 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 provide support for the head and neck during care.
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CEREBRAL PALSY occurs in one-fourth of those who have mental
retardation and tends to affect motor skills more than cognitive skills. Uncontrolled
body movements and reflexes associated with cerebral palsy can make it difficult to
provide care.
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Place and maintain your patient in the center of the dental chair. Do not force arms
and legs into unnatural positions, but allow your patient to settle into a position
that is comfortable and will not interfere with dental treatment.
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Observe your patient's movements and look for patterns to help you anticipate direction
and intensity. Trying to stop these movements may only intensify the involuntary response.
Try instead to anticipate the movements, blending your movements with those of your
patient or working around them.
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Softly cradle your patient's head during treatment. Be gentle and slow if you need
to turn the patient's head.
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Help minimize the gag reflex by placing your patient's chin in a neutral or downward
position.
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Stay alert and work efficiently in short appointments.
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Exert gentle but firm pressure on your patient's arm or leg if it begins to shake.
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Take frequent breaks or consider prescribing muscle relaxants when long procedures
are needed. People with cerebral palsy may need sedation, general anesthesia, or hospitalization
if extensive dental treatment is required.
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CARDIOVASCULAR ANOMALIES such as heart murmurs and damaged
heart valves occur frequently in people with mental retardation, especially those
with Down syndrome or multiple disabilities. To avoid complications, consult the patient's
physician and use the American Heart Association's antibiotic prophylactic regimen
(www.americanheart.org) for dental treatment
when indicated.
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SEIZURES are common in this population but can usually be controlled
with anticonvulsant medications. 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, most commonly strabismus (crossed or misaligned
eyes) and refractive errors, can be managed with careful planning.
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Determine the level of assistance your patient requires to move safely through the
dental 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 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.
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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.
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 in Mental Retardation and Strategies for Care
In general, people with mental retardation have poorer oral health and oral hygiene
than those without this developmental disability. Data indicate that people who have
mental retardation have more untreated caries and a higher prevalence of gingivitis
and other periodontal diseases than the general population.
PERIODONTAL DISEASE. Medications, malocclusion, multiple disabilities,
and poor oral hygiene combine to increase the risk of periodontal disease in people
with mental retardation.
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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.
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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.
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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.
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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.
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DENTAL CARIES. People with mental retardation develop caries
at the same rate as the general population. The prevalence of untreated dental caries,
however, is higher among people with mental retardation, particularly those living
in noninstitutional settings.
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Emphasize noncariogenic foods and beverages as snacks. Advise caregivers to avoid
using sweets as incentives or rewards.
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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.
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Recommend preventive measures such as fluorides and sealants.
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MALOCCLUSION. The prevalence of malocclusion in people with
mental retardation is similar to that found in the general population, except for
those with coexisting disabilities 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.
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MISSING PERMANENT TEETH, DELAYED ERUPTION, and ENAMEL HYPOPLASIA are
more common in people with mental retardation and coexisting conditions than in people
with mental retardation alone.
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Examine a child by his or her first birthday and regularly thereafter to help identify
unusual tooth formation and patterns of eruption.
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Consider using a panoramic radiograph to determine whether teeth are congenitally
missing. Patients often find this technique less threatening than individual films.
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Take appropriate steps to reduce sensitivity and risk of caries in your patients with
enamel hypoplasia.
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DAMAGING ORAL HABITS are a problem for some people with mental
retardation. 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.
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TRAUMA and INJURY to the mouth from falls or accidents occur
in people with mental retardation. 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 mental retardation 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 BK. Mental retardation. In Batshaw ML. Children With Disabilities (5th
ed.). Baltimore, MD: Paul H. Brookes Publishing Co., 2002. pp. 287-305.
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. Dentistry for the Child and Adolescent (7th ed.). St.
Louis, MO: Mosby, 2000. pp. 566-599.
For more information about mental retardation, contact
National Institute of Child Health and Human Development Information Resource Center
P.O. Box 3006
Bethesda, MD 20827
(800) 352-9424
www.nichd.nih.gov
NICHDInformationResourceCenter@mail.nih.gov
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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 cerebral palsy.
Other booklets in this series:
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Continuing Education: Practical Oral Care for People With
Developmental Disabilities
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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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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. 04-5194
Printed May 2004
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