Tips on providing needed care to special patients.
Approximately 13 million people in the United States are developmentally disabled and/or intellectually challenged.1 The term developmentally disabled refers to a severe, chronic disability of a person five years or older that:
• Is attributable to a mental or physical impairment or a combination of mental and physical impairments
• Is manifested before the person reaches age 22
• Is likely to continue indefinitely
• Results in substantial limitations in three or more of the following areas: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, or economic self-sufficiency
• Reflects the person’s need for lifelong or extended special services or other assistance. Until age five, children who have substantial developmental delays or congenital or acquired conditions have a high probability of developing developmental disabilities if services are not provided2
The terms mental retardation, intellectually compromised, or cognitive disability are all politically correct, and mean that a person has substantial limitations in function. This is characterized by sub-average intellectual functioning (an IQ of 70 to 75), and limitations in two or more of the following adaptive skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work. Mental retardation manifests itself before age 18.3
Historically, beginning with the colonization of America in the early 1600s and continuing for the next 300 years, people with disabilities were, for the most part, socially and physically isolated. After World War II, the United States began housing developmentally disabled adults in institutions, where they also received medical and dental care.
Many people believed that those with developmental disabilities could have a more fulfilling life outside of institutions, so they fought for community inclusion. In 1963, President John F. Kennedy passed a law to de-populate institutions for the developmentally disabled. What emerged was the group home setting, which gave people with cognitive and physical disabilities the opportunity to live in single-family homes within their communities. This enabled them to live quality lives in a family atmosphere. Nevertheless, this law created major challenges in our country in regards to medical and dental care. Developmentally disabled individuals continue to depend on state benefits for their medical and dental care, but many medical and dental offices have not broken down the barriers to treat people with developmental disabilities.4
Overcoming the barriers
Many of the individuals in these homes have small jobs that allow them to afford things like regular dental hygiene visits. Many states have limited access hygienists, or alternative care hygienists, who provide treatment for these people in their homes. There are usually three to six people in a home. Having dental care provided in their homes probably allows for a more pleasant experience since it is a comfortable environment for them.
It is important that before treatment of a disabled patient, the conservator or guardian signs a release of liability. This is an explanation of services rendered, and what type of restraints may be necessary due to the individual’s tremors or inaccessibility to an area of the mouth. This is also the time to talk about how payment will be made.
Many of our dental, dental hygiene and dental assistant components provide services in the community to promote the profession of dentistry. One type of community service may be to provide oral hygiene in the homes of disabled individuals. It takes just 30 minutes several times a week to provide oral hygiene care to these people in their homes. Caregivers are overworked, and brushing teeth is last on their list. As a community of dental professionals, we can visit the homes just a few times a week to help with the oral hygiene needs of these people.
The caregivers in these homes attend periodic in-service training, and this is a perfect time for dental professionals to provide training about how to care for the disabled individual’s teeth. Information about the relationship between oral health and systemic health can be an eye opener for those who work with the disabled. This may motivate them to provide good oral hygiene for the people they care for.
■ Toothbrushing - It is scientifically proven that a power brush removes more plaque, which in turn prevents gingivitis and periodontal disease. Power brushes don’t have to be expensive. There are a wide variety of low cost battery operated toothbrushes, and there are grants available to provide power brushes to the developmentally disabled. Various dental companies have programs that will donate these products because it is a tax deduction for the company when an “in kind” donation is given.5
A toothbrush is most effective when used outside of the bathroom. Those who visit the homes should not be confined to providing oral hygiene services in the bathroom. Services can be provided in the kitchen where movement and access to difficult areas in the mouth is easier.
■ Flossing - Flossing is very important for prevention of tooth decay and periodontal disease. Numerous mechanical flossers provide floss on a handle, and some are even battery operated. Flossing can become a part of a daily or nightly routine. Be aware that some disabled individuals may be sensitive to noise or motion. While over time flossing can become routine, there may be an adjustment period needed to slowly introduce new oral hygiene products.
■ Alternatives or adjuncts to flossing - Various dental companies make proxabrushes, which access the interproximal spaces. Sunstar Butler, for example, makes a very small proxabrush called Go-Betweens. The Go-Betweens is small enough to get between contacts as small as 0.9 mm. Interdental brushes help clean the interproximal spaces when individuals resist the use of dental floss.
■ Oral rinses - It has been documented that a .20 percent chlorhexidine rinse can help defer further gingival inflammation and the progression of periodontal disease. One problem with daily use of this product are the tenacious stains that can appear.6
Procter & Gamble has a new over the counter rinse called Crest Pro-Health® Rinse. This alcohol-free rinse containing 0.07 percent cetylpyridinium chloride (CPC) provides antiplaque and antigingivitis benefits. The data supports the antibacterial action of the high bioavailable, alcohol-free CPC rinse and demonstrates antiplaque effects for Crest Pro-Health Rinse that are at least as good as the leading essential oils antiseptic. This makes it well suited for a broad range of patients, particularly those who are sensitive to products containing alcohol. This product is less likely to stain teeth.7
Sunstar Butler also has a new post-op rinse called Rincinol P.R.N.. This product has a bioadhesive coating and doesn’t contain alcohol or peroxide. It also contains aloe vera, which is known for its healing properties. This is a very inexpensive solution not only to heal irritated oral tissues, but also canker sores, which many developmentally disabled adults are susceptible to. This product will not stain the teeth.
Times have changed since people thought it was best to institutionalize people with disabilities. People with developmental disabilities have proven that they can contribute to society and make our world a better place. They deserve the highest level of care, no matter what their cognitive or physical disability.
Treating a person with disabilities may require creativity and flexibility, but the rewards far outweigh the efforts. We need to open our minds, doors and lives by providing quality care to people with disabilities, and remember that good oral health equals total health. It is not a matter of “disability,” but what the “abilities” of these special people can be!
Debra Seidel-Bittke, RDH, BS, is founder of Dental Practice Solutions, a speaking and dental consulting business specializing in a team approach to prevention and nonsurgical treatment of periodontal disease. She may be reached for speaking, questions, or comments at (866) 206-6364 or firstname.lastname@example.org. Visit her Web site at www.dentalpracticesolutions.com.
1. http://www.thearc.org/ga/mrdd.html accessed on June 1, 2005
2. The 1990’s Developmental Disabilities Assistance and Bill of Rights Act can be accessed at: http://wally.rit.edu/pubs/guides/ada.html
3. American Association on Mental Retardation documented in 1992. http://www.aamr.org/
4. Murray, Nancy. Paper presented at The University of Pittsburgh Institute of Politics on May 2, 2003. Paper can be accessed at: http://www.wheelchairnet.org/WCN_Living/Docs/Historicaloverview.html
5. http://www.cochrane.org/cochrane/revabstr/AB002281.htm accessed on May 31, 2005
6. J.Perio, Committee on Research, Science, and Therapy, The Role of Supra- and Subgingival Irrigation in the Treatment of Periodontal Diseases, 1995
7. Witt, J. PhD, et al, Antibacterial and Antiplaque Effects of a Novel, Alcohol Free Oral Rinse With Cetypyrinium Chloride, Winter Issue 2005. Accessed on May 25, 2005 at : http://www.thejcdp.com/issue021/index.htm
Barriers to treatment
for the developmentally disabled
Financial: Medicaid is a federally funded program that is very limited for dental care. Few dentists participate in this program.
Attitudes of caregivers: Caregivers are the people who work in the homes for the developmentally disabled, and they are overworked and underpaid. These people are most likely not taking good care of their own teeth, and don’t understand good oral health and its relationship to good systemic health.
Access to dental offices: These patients rely on alternative transportation to the dental office. They may be in a wheelchair and need assistance transferring into your dental chair.
Fear of accusations: As dental professionals, we may at times need to use physical or mechanical restraint to treat these patients.
Lack of public awareness of available services: When looking through the Yellow Pages under “dentistry,” most dentists advertise as cosmetic or esthetic specialists. How many dentists advertise that they treat disabled patients?