Periodontal Care for Patients with Special Needs

More than 51 million people in the United States have some form of disability.¹ Disabilities affect all age groups, including 4 million children and almost three-quarters of individuals 80 years and older.¹ In the year 2000, births in the United States included 12,500 children with cerebral palsy, 5,000 with hearing loss, 4,400 with vision impairment, 5,000 with heart malformations, 5,500 with other circulatory/respiratory anomalies, 800 with spina bifida/ meningocele, 3,300 with cleft lip/palate, and 8,600 with a variety of musculoskeletal/integumental anomalies.²

With numbers like these, most dental practices will treat individuals with varying degrees of physical and/or intellectual disabilities. As such, dental professionals need to be pre- pared for the specific issues this patient population may bring. For example, patients who have intellectual disabilities may not understand the need for oral hygiene, and patients with physical disabilities may not be able to perform oral hygiene tasks because of physical limitations.³

Periodontal Diseases

Periodontal diseases are caused by specific microorganisms that create inflammation in the oral cavity’s supporting tissues, leading to the destruction of the periodontal ligament and alveolar bone through the formation of pockets, recession, or both.⁴ In response to microbial substances released from plaque, bacteria in the gingival sulcus, epithelial, and connective tissue cells produce inflammatory mediators, causing the infiltration of connective tissue by numerous defense cells. In susceptible individuals, however, the primary host defenses are unable to control the microbial challenge and the epithelium becomes increasingly permeable and ulcerated.⁴

Overcoming Barriers

Patients with disabilities who have progressive periodontitis need help in developing the necessary strategies to impede the disease process.⁵ Patients with special needs face three types of barriers in the prevention of dental disease: informational, physical, and behavioral. Informational barriers include a lack of understanding about effective practices to prevent periodontal disease. Caregivers must be educated about the benefits of oral preventive practices, as well as the correct techniques needed to accomplish them.

Physical barriers include lack of musculature, dexterity, or coordination to perform the preventive tasks. There are numerous adaptations and aids that can help patients overcome these physical barriers, including toothbrushes with larger handles and adaptations for floss holders.

Behavioral barriers can be overcome by choosing a place or time of day that is more conducive to gaining cooperation; involving the individual in the choice of when to carry out the preventive procedures; and using reinforcers as rewards (caregiver smiling and praise) to encourage independence in oral hygiene practices.³

Intellectual Disabilities

Intellectual disability is a disorder of mental and adaptive functioning. It is not a disease or mental illness, but rather a developmental disability that varies in severity and may be associated with cerebral palsy, seizures, and communication difficulties. Before an appointment, it is essential to obtain and review the patient’s medical history. Dental professionals must also understand who is legally allowed to give informed consent for treatment.⁶

People with intellectual disabilities learn slowly and often with difficulty. Ordinary activities of daily living, such as brushing teeth, getting dressed, and correctly interpreting the behavior of others, can all present challenges.

The following strategies are helpful when setting up an appointment with patients who have intellectual disabilities:

• All members of the staff should be aware of the patient’s intellectual limitations.
• Schedule patients as early in the day as possible. Medications are often most effective in the morning, and office waiting time is typically shorter than later in the day.
• Keep appointments brief and postpone difficult procedures until after the patient is familiar with the practice and staff.
• Allow extra time for patients to get comfortable with clinicians.
• If parents or caregivers can be supportive, have them accompany the patient into the treatment setting to provide familiarity, help with communication, and offer a calming influence.
• Use medical immobilization/protective stabilization techniques only when necessary to protect the patient and staff.
• Reduce distractions in the operatory, such as unnecessary sights, sounds, or other stimuli. For some patients, a television can provide a positive diversion.
• Talk with the parent or caregiver to determine the patient’s intellectual and functional abilities.
• Address the patient directly.
• Use simple concrete instructions. Speak slowly and give only one direction at a time.⁶

Table 1. Steps to reduce the risk of aspiration pneumonia in patients with a nasogastric tube.13,14 1. More frequent recare examinations, scalings, and polishings may be necessary to ensure oral hygiene. 2. The use of ultrasonic and sonic scalers and air/water syringes should be avoided. 3. High and/or low-volume suctioning should be used to prevent aspiration of calculus fragments during manual scaling. 4. Because proper positioning maximizes the effectiveness of protective airway reflexes, the patient’s body should be vertically symmetrical with neutral head flexion, an elongated neck, and depressed shoulders.

Down Syndrome

Down syndrome is an autosomal chromosomal disorder resulting from trisomy of all or part of chromosome 21. Approximately 95% of people with Down syndrome have an extra complete chromosome 21.⁷ The incidence of Down syndrome is approximately one in 733 live births—and that risk increases with maternal age, reaching one in 109 live births among 40 year-old women.⁷

The prevalence of periodontal diseases among Americans ranges from 29% for people age 19 years to 45 years, to 50% for those 45 years and older.⁸ An increased prevalence of severe periodontal disease has been reported among people with Down syndrome, ranging between 58% and 96% for those under 35 years of age.⁸

Managing periodontal diseases in patients with Down syndrome is challenging. The most likely explanation for why individuals with Down syndrome and intellectual disabilities have higher plaque scores and gingival inflammation is their inability to practice adequate personal hygiene independently.⁹ In order to maintain their oral health, people with Down syndrome need good motor skills and self-control, or a cooperative relationship with a caregiver who has the skills and desire to maintain an effective oral health regimen.¹⁰ Other issues include:

• Open-mouth breathing: People with Down syndrome exhibit an underdeveloped facial mid-third, which results in a hypoplastic maxilla and mandibular prognathism. The hypoplastic maxilla, combined with enlarged tonsils, causes upper airway congestion and a tendency toward mouth-breathing.⁸
• Tooth morphology: There are irregularities in the morphology of crowns and roots in individuals with Down syndrome. Crowns are usually shorter and smaller and root lengths are minimized with an increased prevalence of fused molar roots.⁸ Shortened root lengths may impose limitations on orthodontic services.
• Hyper-innervation of the gingiva: This may be caused by inflammation initiated by chemical transmitters in the nerves.⁸

Depending on the intellectual capacity of patients with Down syndrome, the suggested steps for patients with intellectual disabilities are applicable.

Cerebral Palsy

Cerebral palsy is a disorder of movement, muscle tone, or posture that is caused by injury or abnormal development in the immature brain, most often before birth. Symptoms appear during infancy or preschool years. In general, cerebral palsy causes impaired movement associated with exaggerated reflexes or rigidity of the limbs and trunk, abnormal posture, involuntary movements, and unsteady gait. The effect of cerebral palsy on functional abilities varies greatly.¹¹ Cerebral palsy occurs in one-fourth of those who have an intellectual disability and tends to affect motor skills more than cognitive skills. Uncontrolled body movements and reflexes can make it difficult to provide care. For the dental appointment:

• Place and maintain the patient in the center of the dental chair. Do not force arms and legs into unnatural positions, but allow the patient to settle into a position that is comfortable and will not interfere with dental treatment. The use of a chair pad may improve comfort.
• Observe the patient’s movements and look for patterns to help anticipate direction and intensity of movement. Do not confuse involuntary movements with lack of cooperation. Trying to stop these movements may only intensify the involuntary response. Softly cradle the patient’s head during treatment. Be gentle and slow when turning the patient’s head.
• Help minimize the gag reflex by placing the patient’s chin in a neutral or downward position.⁶

Hearing Loss and Deafness

Patients with hearing problems may want to adjust their hearing aids or turn them off because the sound of some instruments may cause auditory discomfort. For the dental appointment:

• If the patient reads lips, speak in a normal cadence and tone. If the patient uses a form of sign language, request an interpreter. Speak with the interpreter in advance to discuss dental terms and the patient’s needs.
• Before talking, eliminate background noise (eg, radio and suction). Sometimes people with hearing loss simply need to be spoken to in a clear and slightly louder voice. Remember to remove your face mask when talking or wear a clear face shield.⁶

Visual Impairments

Determine the level of assistance the patient requires to move safely through the dental office. Use the patient’s other senses to connect with him or her. For the dental appointment:

• Face the patient when speaking and keep him or her 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.⁶

Seizures

According to the Epilepsy Foundation, 3 million Americans have some form of seizure disorder or epilepsy, and 200,000 new cases are diagnosed each year.¹² Seizures can usually be controlled with anticonvulsant medications. Some medications, such as Dilantin, may cause gingival overgrowth, thus increasing the risk of periodontal disease, tooth decay, and oral infections, as well as delayed exfoliation of the deciduous dentition and delayed eruption of permanent dentition.

The oral cavity is always at risk during a seizure. Patients may chip teeth or bite the tongue or cheeks. However, people with controlled seizure disorders can easily be treated in the general and periodontal dental office. For the dental appointment:

• Determine before the appointment whether medications have been taken as directed. Know and avoid any factors that trigger a patient’s seizures. For example, using a shield to block light emitted by the dental chair.
• 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 mouth props when treatment begins can facilitate their quick removal. Do not attempt to insert any objects between the teeth during a seizure.
• Stay with the patient, turn him or her to one side, and monitor the airway to reduce the risk of aspiration.⁶

Nasogastric Tube

Patients with a nasogastric tube (a plastic tube that is inserted through the nose, past the throat, and down into the stomach) have feeding disorders that make it unsafe for them eat by mouth. The most common diagnoses associated with tube-feeding are cancer and neuromuscular swallowing disorders. The typical patient fed by a tube has abundant calculus, low caries activity, and the potential for dental erosion related to gastroesophageal reflux disease (GERD). Aspiration pneumonia is a major concern for these individuals, particularly in the presence of poor oral hygiene and unrestored carious lesions. Clinicians should strive to reduce the pathogenic bacterial count in oropharyngeal secretions because they will probably be aspirated in the presence of tubefeeding. Table 1 provides steps to reduce the risk of aspiration pneumonia.^13,14 Maintaining oral health can reduce the morbidity and mortality caused by aspiration pneumonia.^13,14

Prevention is Key

Providing periodontal care to patients with disabilities is paramount to their health. These patients experience more dental disease, more missing teeth, and more difficulty receiving dental care than the population at large.¹⁵ It is up to dental professionals to ensure they receive appropriate care.¹⁵

As with all patients, preventive measures are essential to maintaining the oral health of individuals with disabilities. These efforts should include:

Mouthrinses. Many oral health rinses are available for controlling gingivitis (eg, those containing cetylpyridinium chloride, chlorhexidine, delmopinol, essential oils, stabilized chlorine dioxide, triclosan, etc).

Mechanical toothbrushes. Lowcost mechanical toothbrushes are essential for both physically compromised patients as well as for caregivers who assist patients with disabilities.

Fluoride varnish. The adherent nature of fluoride varnish enables it to stay in contact with the tooth surface for several hours, providing maximum benefits for patients with disabilities. It may be applied to the enamel, dentin, or cementum of the tooth, and can be used to help prevent decay, remineralize the tooth surface, and to treat dentinal hypersensitivity. However, if the patient or caregiver does not brush thoroughly the day after the application, the varnish can serve as a platform for rapid calculus formation.

Dental floss. Special floss holders are available for patients with physical disabilities. Interdental brushes, picks, and other devices are more user-friendly than traditional floss and may provide more effective plaque biofilm removal.

Tongue cleaning. The top surface of the tongue should be scraped once or twice daily to reduce the number microorganisms in the mouth.

Conclusion

Providing oral health care for individuals with disabilities requires adapting the skills that dental professionals use in everyday practice. Dental professionals are experienced in modifying their communication for patients of all ages and those who are apprehensive or phobic. By using these same skills and considering the particular needs of patients with disabilities, dental professionals can achieve success in treating this often neglected patient population.

References

1. Disabled in Action. Facts about disabled in the US population. Available at: www.disabledinaction.org/census_stats.html Accessed August 28, 2011.
2. Centers for Disease Control and Prevention. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment—United States, 2003. MMWR Mortal Wkly Rep. 2004;53:57-59.
3. Glassman P, Miller C. Dental disease prevention and people with special needs. J Calif Dent Assoc. 2003;31:149-160.
4. Cichon P, Crawford L, Grimm WD. Early-onset periodontitis associated with Down’s syndrome— clinical interventional study. Ann Periodontol. 1998;3:370-380.
5. Christensen GJ. Special oral hygiene and preventive care for special needs. J Am Dent Assoc. 2005;136:1141-1143.
6. National Institute of Dental and Craniofacial Research. Practical oral care for people with intellectual disability. Available at: www.nidcr.nih/gov. Accessed August 28, 2011.
7. CDC study on the prevalence of Down syndrome. Available at: www.ndss.org/index.php?option=com_content&view=article&id=153%3A position&limitstart=2. Accessed August 28, 2011.
8. Morgan JM. Why is periodontal disease more prevalent and more severe in people with Down syndrome? Spec Care Dent. 2007;27:196-201.
9. Khocht A, Janal M, Turner B. Periodontal health in Down syndrome: contributions of mental disability. Spec Care Dent. 2010;30: 118-123.
10. Schonfeld SE. Using community-based protocols to prevent dental disease in people with special needs: periodontal prevention and intervention. Spec Care Dent. 2003;23:187-188.
11. Cerebral Palsy. Available at: www.mayoclinic.com/health/cerebral-palsy/DS00302. Accessed August 28, 2011
12. Epilepsy Foundation. About epilepsy. Available at: www.epilepsyfoundation.org/about epilepsy/. Accessed August 27, 2011.
13. Dyment HA, Casas MJ. Dental care for children fed by tube: a critical review. Spec Care Dent. 1999;19:220-224.
14. Casas M. Calculus in children fed by tube: reducing the risk of aspiration pneumonia. J Southeastern Soc Ped Dent. 2002;8;14-16.
15. Glassman P, Miller CE. Preventing dental disease for people with special needs: the need for practical preventive protocols for use in community settings. Spec Care Dent. 2003;23: 165-167.

From Dimensions of Dental Hygiene. September 2011; 9(9): 78-80, 83.