Oral Healthcare for Patients With Disabilities

The federal Healthy People initiative has provided a framework to address health disparities and improve the overall health of Americans. Healthy People 2010 provides an action agenda for the beginning of the 21st century and details health-promotion strategies to increase quality and years of healthy life and eliminate health disparities. This framework helps coordinate the efforts of the research, service, education, and policy-making communities.¹

ORAL HEALTH OF PATIENTS WITH DISABILITIES

In disabled individuals, the process of developing gingival/periodontal diseases does not differ from nondisabled individuals. Disease prevention and treatment modalities also do not differ between these groups.² The main factor related to gingival/periodontal problems in disabled individuals is the inadequacy of plaque removal from the teeth. Motor coordination problems and muscular limitations in neuromuscularly disabled individuals and the difficulty in understanding the importance of oral hygiene in mentally disabled individuals have resulted in the progression of inflammatory diseases.3 Many places where these individuals reside refer to them as “clients.” For the purpose of this article, you will find these individuals referred to not only as patients but also as “clients.”
Preventive care should be emphasized. Treat-ment plans may need to be altered on an individual basis due to the patient’s level of functioning, but the overall goal should be comprehensive care. For example, areas of dental care such as cosmetic dentistry, orthodontics, prosthodontics, and maxillofacial surgery should not be ruled out simply because the patient has Down syndrome.

THE CHALLENGES
Most clients with Down syndrome will have IQs in the mild to moderate range of impairment and are able to be treated in the normal office setting. There is often a severe language delay, with receptive language being at a much higher level than expressive language. Thus, the patient with Down syndrome may be able to understand more than is apparent. The help of the patient’s family or caregiver may be needed for the operator to determine the level of communication appropriate for the patient. A greater than normal incidence of epilepsy is also seen in patients with Down syndrome, particularly adult-onset type.⁴
Many patients who come to the dental office with health disparities need special help getting into the dental chair. For instance, if a patient has cerebral palsy, we may need to transfer him or her from a wheelchair to the dental chair. For those who are deaf, we may need to use some sign language to communicate. For some of these patients, we may need to adapt oral hygiene devices so the patient can use them.⁵
Other patients have medical and oral conditions that call for extraordinary care and require oral health professionals to have specialized knowledge. Surgical treatment of oral cancer or genetic craniofacial defects such as cleft lip and palate often requires extensive reconstruction that involves many health specialists.
With Down syndrome also comes an increase in the incidence of Alzheimer’s disease. Studies vary, but the incidence ranges from 30% to 90% of this population showing signs of Alzheimer’s disease.⁶
Many of these patients require attention for serious medical needs, and oral care becomes last on the list of important issues of concern. Most of these patients can be treated in the general practice with little or no adaptations. Most undergraduate dental programs do not expose students to patients with disabilities, and general practitioners may be hesitant to attempt treatment of this population. It is important for oral healthcare providers to coordinate the oral health of the patient with all members of the patient’s healthcare team, including medical professionals and caregivers.
Determine each patient’s mental capabilities and communication skills. Talk with caregivers about how the client’s abilities might affect oral healthcare. Be receptive to their thoughts and ideas on how to make the experience a success. Allow time to introduce concepts in language that patients can understand. Communicate respectfully with your patients and comfort those who resist dental care. Repeat instructions when necessary and involve your patients in hands-on demonstrations.

BEHAVIOR PROBLEMS

Behavior problems can complicate oral healthcare. 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:

(1) 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 and/or hygienist in the operatory.
(2) Arrange for a desensitizing appointment to help the patient become familiar with the office, staff, and equipment before treatment begins.
(3) 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.
(4) 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.

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 (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.

MOBILITY PROBLEMS

Many people with disabilities rely on a wheelchair or a walker to move around.
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.
Keep the space in the operatory open with room to move when mobility problems exist.
Ask the patient or caregiver about special preferences should you need to transfer a patient from a wheelchair. Some patients will require padding or special pillows. Often the patient or caregiver can explain how to make a smooth transfer. There are times when patients cannot be moved from their wheelchair, and in this case they 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.

NEUROMUSCULAR PROBLEMS

There are some types of disabilities where patients will experience persistently rigid or loose masticatory muscles. Others have drooling, gagging, and swallowing problems that complicate oral care. Muscle hypotonia is associated with Down syndrome. This decrease in muscle tone occurs throughout the body and tends to improve with age. This hypotonia affects the balance of forces required for normal facial development. Reduced muscle tone in the lips and cheeks contributes to the open bite commonly seen in Down syndrome. Additionally, reduced muscle tone causes less efficient chewing and natural cleansing of the teeth.
When a patient has a gagging problem, schedule an early morning appointment before he or she eats or drinks. Help minimize the gag reflex by placing your patient’s chin in a neutral or downward position. If your patient has swallowing problems, tilt the head slightly to one side and place his or her body in a more upright position.
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.

INVOLUNTARY BODY MOVEMENTS

This can cause a safety problem and may hinder your ability to deliver dental care. Pay special attention to the following considerations:
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.
Patient’s position. It is important to 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. Padding or pillows can help maintain a comfortable position.
Your position. Spend time observing 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.

CARDIAC DISORDERS

Fifty percent of Down syndrome patients are known to have congenital heart disorders that place them at risk for bacterial endocarditis. Prescribe antibiotic prophylaxis when indicated (heart.org). Contact your patient’s primary care physician if you have questions about his or her medical history.

SEIZURES
Seizures may accompany many disabilities. If this occurs in the dental office, the mouth is at great risk. Patients may chip teeth or bite the tongue or cheeks. Persons with controlled seizure disorders can easily be treated in the general dental office.
Consult your client’s physician or the patient’s personal care assistant (PCA). Ask healthcare providers about the patient’s history of seizures and record information in the chart about the frequency of seizures and medications used to control them. When a patient with a history of seizures sits in the dental chair, always ask at the beginning of the appointment whether medications have been taken as directed. Know and avoid any factors that trigger your patient’s seizures.
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.
Stay with your client, turn him or her to one side, and monitor the airway to reduce the risk of aspiration.

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. Ask patients and caregivers about the presence of a latex allergy before you begin treatment.
Schedule appointments for your latex-allergic or latex-sensitive patients at the beginning of the day when there are fewer airborne allergens circulating through the office. Use latex-free gloves and equipment and keep an emergency medical kit handy.

OROFACIAL FEATURES
The patient with Down syndrome has an underdevelopment of the midface. This causes a prognathic or class III relationship in many cases. This prognathism contributes to the open bite. There often is an absence or reduction of the frontal and maxillary sinuses, and the palate appears narrow and deep. The palate is usually of normal height, but the sides of the palate may be very thick, resulting in less space for the tongue. This also may complicate retention of maxillary complete dentures to the extent that surgical correction may be indicated.⁷

SOFT TISSUES

Many patients with disabilities have a high incidence of mouth breathing, especially in the Down syndrome patient. This is due to a small nasal airway and the presence of chronic upper respiratory infections. The tongue may protrude and appear to be too large; it actually is of normal size, but the oral cavity is a decreased size due to underdevelopment of the midface. Speech pathologists can be helpful in teaching the correct tongue position and increasing muscle tone of the orofacial musculature.

ORAL HEALTH PROBLEMS AND STRATEGIES FOR CARE

Eruption times for both the primary and permanent dentition are usually delayed in Down syndrome patients. This delay in eruption may be as long as 2 to 3 years, and teeth may erupt in an unusual order.⁸ The percentage of missing and malformed teeth is very high as well. About 30% to 60% of Down syndrome patients will be missing the lateral teeth, but it is also known that various other teeth can be missing. When tooth eruption is delayed, children may stay bottle fed for a longer time. As toddlers, they may need to have an altered diet because they don’t have enough teeth to chew food properly. Due to this delay in eruption, a child’s family may not perceive the need for early dental visits.⁹ The roots also tend to be small, and a large percentage of molars exhibit elongated pulp chambers.¹⁰
People with developmental disabilities are not predisposed to periodontal disease or dental caries. However, other related healthcare issues cause the oral healthcare problems. Many of these patients have low IQs and low-level motor skills. The caregivers are overworked, and assisting a special needs person with his or her teeth goes to the bottom of the “to-do” list.
Educate clients and caregivers about the cariogenic nature of sugar in the diet, the adverse side effects of certain medications, and the importance of regular brushing and flossing. Recommend preventive measures such as fluorides and sealants.¹¹

ORAL HYGIENE PROGRAM

Location. Explain to caregivers that the bathroom isn’t the only place to brush someone’s teeth. For example, the kitchen or dining room may be more comfortable. Instead of standing next to a bathroom sink, allow the person to sit at a table. Place the toothbrush, toothpaste, floss, and a bowl and glass of water on the table within easy reach. No matter what the location, advise the caregiver to have good light. He or she cannot help the patient brush unless the inside of the mouth is visible.
Behavior. Problem behavior can make dental care difficult. Try these ideas and see what works for you:
At first, dental care can be frightening to some people. Try the tell-show-do approach to deal with this natural reaction. Tell the client about each step before you do it. For example, explain how you’ll help him or her brush and what it feels like. Show how you’re going to do each step before you do it. Also, it might help to let your client hold and feel the toothbrush and floss. Do the steps in the same way that you’ve explained them.
Give your client time to adjust to dental care. Be patient as that person learns to trust you working in and around his or her mouth. Use your voice and body to communicate that you care. Give positive feedback often to reinforce good behavior.
Have a routine for dental care. Use the same technique at the same time and place every day. Many people with developmental disabilities accept dental care when it’s familiar. A routine might soothe fears or help eliminate problem behavior.
Be creative. Some caregivers allow their clients to hold a favorite toy or special item for comfort. Others make dental care a game or play a person’s favorite music.
Ask clients 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.
Recommend toothbrushes and flossing devices that are conducive for use when a patient has motor skill difficulties.
Educate the caregivers about daily oral hygiene and do not assume they know the basics. Each client will have a different situation regarding education and the way he or she learns, so teach each patient oral care techniques with the caregiver and demonstrate the sitting or standing positions when cleaning the patient’s teeth. Emphasize that a consistent approach to oral hygiene is important—caregivers should try to use the same location, timing, and positioning.
Many clients with disabilities need to be on a frequent recare schedule with a registered dental hygienist. This will not only help prevent periodontal problems, but possibly allow fluoride treatments to be given. This is a good time to assess the client’s home care and refresh the patient and caregiver on the home care instructions. Frequent dental hygiene visits mean shorter intervals of high plaque buildup, which over many years can make a significant change.

PREPARATION
Always take time to make special preparations for these patients. Remember, you have a wealth of information and can become a source of inspiration not only for the client but for the healthcare employee who may be accompanying the patient. If you have questions prior to the client’s appointment, don’t hesitate to contact the healthcare facility, the patient’s PCA, or the patient’s physician.

• Always make detailed notes in the client’s chart.
• Notify other members of the dental team who may not be familiar with the client and will come in contact with him or her that day.
• Ask the client’s caregiver to bring a list of all medications that are being taken.
• Always be on time.
• Know who can legally consent to treatment.
• Know who will be responsible for paying the bill.

CONCLUSION
In the disabled population, a tendency has been shown to develop gingival/periodontal diseases.¹² If dental care and health awareness is instituted early and supported by parents or caregivers, then home efforts or complicated treatment needs can be kept to a minimum. Also, the amount of plaque removed from the teeth of disabled, institutionalized children or adults can be increased through an in-service educational program for institutional employees. It is imperative that we have more effective modalities of controlling inflammatory periodontal disease in this population. The dental problems and the needs of the disabled population have to receive proper attention to improve quality of life.
On October 10, 2001, Sur-geon General David Satcher, MD, PhD, held the first-ever Surgeon General’s Listening Session on Health Disparities and Mental Retardation. The session was a major component of the surgeon general’s effort regarding the relationship between health disparities and mental retardation, a national dialogue to better understand and address the many severe and often unmet health needs of people with mental retardation. The keystone of the effort is reaching out to mentally retarded individuals, their families and providers, advocacy groups, and community-based organizations that are on the front lines daily trying to protect and promote this population’s health and well being. This is in line with Healthy People 2010. Soon we will see a major impact on the way these patients receive treatment. It is important for all healthcare professionals to re-main abreast of the lastest research about treating patients with disabilities.¹³

References

1. Health for all: reducing health disparities through research and research-related activities. National Institute of Dental and Craniofacial Research Web site. Available at: http://www.nidcr.nih.gov/Research/HealthDisparities/HealthDispOverview.htm. Accessed January 11, 2005.
2. Tesini DA. An annotated review of the literature of dental caries and periodontal disease in mentally retarded individuals. Spec Care Dentist. 1981;1:75-87.
3. Cutress TW. Periodontal disease and oral hygiene in trisomy 21. Arch Oral Biol. 1971;16:1345-1355.
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7. Scully C. Down syndrome and dentistry. Dent Update. 1976;3:193-196.
8. Ondarza A, Jara L, Munoz P, et al. Sequence of eruption of deciduous dentition in a Chilean sample with Down syndrome. Arch Oral Biol. 1997;42:401-406.
9. Kelsen AE, Love RM, Kieser JA, et al. Root canal anatomy of anterior and premolar teeth in Down syndrome. Int Endod J. 1999;32:211-216.
10. Peretz B, Shapira J, Farbstein H, et al. Modified cuspal relationships of mandibular molar teeth in children with Down syndrome. J Anat. 1998;193(pt 4):529-533.
11. Vittek J, Winik S, Winik A, et al. Analysis of orthodontic anomalies in mentally retarded developmentally disabled (MRDD) persons. Spec Care Dentist. 1994;14:198-202.
12. Tesini DA. An annotated review of the literature of dental caries and periodontal disease in mentally retarded individuals. Spec Care Dentist. 1981;1:75-87.
13. Closing the gap: a national blueprint to improve the health of persons with mental retardation. Report of the Surgeon General’s conference on health disparities and mental retardation. Goal 6: increase sources of health care services for adults, adolescents, and children with mental retardation, ensuring that health care is easily accessible for them. Available at: http://www.nichd.nih.gov/publications/pubs/closingthegap/sub11.htm. Accessed January 8, 2005.

Ms. Seidel-Bittke is founder of Dental Practice Solutions, an evolutionary dental consulting business specializing in a team approach to treating periodontal disease while raising the value of patient services. She graduated from the University of Southern California with a bachelor’s degree in dental hygiene in 1984. She is a former clinical assistant professor at USC and most recently has been a guest lecturer for the Contemporary Practice Management course there. She can be reached for comments, consulting, or to schedule speaking for dental conferences at (866) 206-6364, info@dentalpracticesolutions.com, or by visiting dentalpracticesolutions.com.