It was a beautiful summer Friday night, and I was babysitting my 5-year-old twin nephews and my 2-year-old niece. We had just finished watching a Disney movie for the third time, and now it was time to have them brush their teeth. To my surprise, they were not as excited about this as I was.
After many attempts to get them into the bathroom to brush, I started thinking about how I was going to communicate with them and make this process fun and easy, making them want to brush. Then it hit me; I was going to use the tooth brushing application I downloaded on my tablet. The kids were so intrigued by the computer and the application that all three of them ran to the bathroom, put toothpaste on their brushes, and stood at the sink, waiting for the music and video to start. They had their eyes focused on the screen, toothbrushes poised and ready to brush the upper right quadrant as the application instructed them to do.
The timer started, the arms began to move back and forth, and I sat back and watched. Their eyes did not stray from the video, and they followed the brushing pattern precisely. After two minutes, they asked to do it again. The kids brushed for six minutes that night, and I was happy.
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How we connect with our patients is of the utmost concern and importance. Our communication skills should be professional, clear, understandable, and individualized. The dental office patient population may be a melting pot of clients.
The clientele may include special needs individuals for whom communication skills will need to be modified. Interaction with the special needs population requires adjustments to instructions and appointments and should be performed with respect to the individual. Unfortunately, there are a few major misconceptions that need to be addressed when working with persons having intellectual disabilities.
The first misconception is that persons with intellectual disabilities have no awareness or understanding of their disabilities. The reality is that they do and can, most of the time, describe their disability in detail.
A second misconception is that persons with intellectual disabilities are unaware of the demeaning way they are treated by society, especially by professionals. The reality is that most people with intellectual disabilities do not like to be confined in institutions, told how and what to do with their lives, stared at, made fun of, or patronized by professionals. Special needs individuals, all too often, are treated as though they are perpetual children who cannot understand directions and instructions when, in fact, many intellectually disabled individuals can speak several different languages, identify dates without the use of a calendar, perform advanced mathematic skills, and draw amazing pictures. They can follow directions and instructions as well as anyone else as long as it is communicated appropriately.
It is important to take time to learn about the individual in your chair. Do not underestimate the abilities of a disability.
The approach to intellectual disability
Understanding the ability of your patient will help in modifying the appointment and oral hygiene instructions. Intellectual disability (ID) is a disability characterized by limitations in intellectual functioning and results in the need for extraordinary supports for the person to participate in activities involved with typical human functioning (Wehmeyer M, Obremski S, 2010). As is now commonly accepted, ID requires assessments of adaptive skills (communication, self-help, community living, and social) and intellectual functioning two standard deviations below the mean (Pipan M, 2012).
Persons with an IQ below 70 that exhibit behavioral problems, are unable to care for themselves on a daily basis, have communication disadvantages, and are unable to participate in community activities on their own are classified as special needs individuals. Special needs individuals with intellectual disabilities can be classified as mild, moderate, severe, or profound.
Mild disabilities account for 85% of people with ID. Individuals usually meet elementary academic levels or beyond with sufficient support, and most can live independently with a minimal level of additional support. These individuals will require more time, instructions, and reminders for other daily life activities.
Persons with a moderate ID include approximately 10% of the intellectual disability population. Individuals in this range have adequate communication skills, but complexity is more limited. Self-care activities can be performed but may require extended instruction and support.
Severe intellectual disability defines 3% to 4% percent of the ID community. Communication skills are very basic. Daily self-care activities require assistance.
Profound individuals account for a minor population of intellectual disabilities, 1% to 2%. A profound individual is reliant upon others for all aspects of daily living, and communication skills are extremely limited.
Having a basic understanding of the classification of intellectual disabilities will help the oral health-care practitioner provide the best individualized care.
Intellectual Disability and Hearing Impairment
My practice is composed of individuals with intellectual disabilities as well as individuals with hearing impairments. Communication with my patients experiencing intellectual and hearing challenges requires a modified interaction technique. Consideration to the patient is of utmost importance. It is important to understand what level of intellectual disability and hearing challenges the individual has to best communicate during the appointment and to customize oral hygiene instructions.
A 52-year-old male patient with a moderate intellectual disability and a slight hearing impairment stated to me that he was learning to write his name at his day program. The information I received from his medical history review and from verbally questioning the patient about how his day went provided me with information as to what level of education I should use to instruct him in oral hygiene care.
In addition, his hearing impairment also made me rethink my oral hygiene strategy. The client did not wear hearing aids, so additional techniques to communicate clearly with the client needed to be considered. I needed to think about what method of communication was going to be the best way to relay my message so my patient could understand what I wanted to teach him.
The best way for me to effectively communicate with the client was to wait until the end of the appointment when I could remove my mask so my patient could hear more clearly, my voice would not be muted and inaudible, and the client would be able to read my lips. Also, I reduced any background noise that may have interfered with our verbal interaction. Since his hearing impairment was reduced in both ears, I stood in front of the patient when I provided oral hygiene instructions.
In most cases, the patient will inform you if there needs to be any adjustments made in your tone or the volume of your voice. Hearing impairments may not be equal in both ears. Some clients may have a stronger audible range capability in one ear over the other, in which case it is best to speak on the dominant side so the client has a better chance of understanding and comprehending directions and instructions.
Individuals with advanced hearing loss may use sign language. If the situation presents, ask the care provider to stay in the operatory during the appointment to translate. Additionally, the use of the ultrasonic instrument should be discussed with the patient prior to use due to the high pitched noise produced by the unit, which could be irritating and uncomfortable to the client. The individual may elect to remove the hearing aid(s) prior to ultrasonic use.
To address his intellectual disability, I provided oral hygiene instructions on a basic level, which my patient could understand. I used layman’s language in place of professional terminology, explaining how to place the toothbrush where the tooth meets the gum tissue. In addition, I demonstrated the correct placement of the toothbrush with the use of a mirror and small toothbrush. The visual of the toothbrush location, for this patient, had a greater impact on his ability to understand the correct angle of brushing. Instructing the client to place the toothbrush at a 45-degree angle was excessive information and complicated direction for this particular patient to visualize and understand, but using a mirror to show the correct alignment of the toothbrush had a significant impact on his understanding of the ideal toothbrush position. The picture created in the mirror was worth a thousand words.
Intellectual Disability and Sight Impairment
My next day of dental hygiene services took me to a group home. The gentlemen residing in this particular home had various degrees of sight impairments as well as mild to moderate intellectual disabilities. It is important to establish a rapport with every client; however, I feel it is extremely important to establish a bond with sight-impaired clients. They may rely on the dental hygiene professional to walk them to the operatory, and they will be trusting you with their oral health care.
Expressing a warm, sincere handshake or a compassionate touch on the shoulder will help develop a trusting relationship and may calm anxiety the client is experiencing internally without demonstrating external signs. It is appropriate and recommended that the sight impaired individual be guided to the operatory. When escorting the client to the treatment room, the client should be given thorough directions and should be supported by holding a hand or placing a hand on the client’s shoulder. In addition, the pathway should be clear of obstacles.
Each appointment was tailored to address the needs of each gentleman, and oral hygiene instructions were customized to accommodate the intellectual disability of the individual. Clients experiencing sight impairments have an increased sensitivity in their other senses. It is advisable to explain the sounds coming from any equipment used during the dental hygiene appointment. Educating the client on the different noises will help prevent unanticipated movement from the client and will help prevent accidents.
Tooth brushing instructions, for most of the men, were performed chairside. The clients were given a child-size manual toothbrush. The brush was placed at the correct angle in the patient’s mouth and detailed brushing information was explained concisely and slowly so the individuals could comprehend the instructions. Placing the brush at the correct position helped the gentlemen reproduce the same toothbrush position by remembering the feeling of the bristles on the gums.
For these gentlemen, hands-on learning is the best technique to understand how to correctly place the brush. Guiding the patient’s hand when providing brushing instruction is necessary and acceptable. Applied demonstration offers them the ability to engage their tactile sense, which will help them remember the correct placement of the brush. In addition to using tactile sense as a method of teaching, explaining and detailing how to perform oral hygiene care is beneficial. Involving the individual in the learning process is important for patient comprehension. Asking the patient to repeat what was said throughout the oral hygiene educational process reinforces what the patient has been taught and helps the patient remember the steps or guidelines.
This is another time in which detailed information is essential. When I treat the residents at their home, I set up my operatory in the bathroom. The residents are familiar with the room setup but still need guidance to sit in the chair. It is important for me to hold their shoulders, cradle the elbow of the arm closest to me, and instruct them on how many steps to the right or left to move so they do not trip and fall. Touching the patient below the shoulder on the torso is not recommended due to privacy concerns. If a medical issue arises, do what needs to be done to keep the patient safe.
Some special needs individuals may require assistance when performing oral hygiene tasks. This assistance may come from family, friends, or a paid support-care individual. The support provider may be in the room with the patient and health-care provider, but the patient should always be given the health provider’s primary attention. Treat the individual with respect, and always speak directly to the patient. Provide the oral hygiene instructions to the patient first, and then review them with the support member. Another approach is asking the patient’s permission to review oral hygiene instructions with the patient and the support member at the same time. Always respect the individual’s wishes. Communication is a valuable tool; use it wisely, and it will provide great benefits. RDH
Brenda Kibbler, RDH, RDHAP, BHSc, is a professional speaker, consultant, and business owner. Her independent dental hygiene practice, Dental Hygiene For The Homebound, provides specialized and individualized dental hygiene treatment to medically and physically compromised patients. She is a recipient of the 2013 Sunstar/RDH Award of Distinction. Brenda can be reached at [email protected]. Visit her website at hygienehousecalls.com.
References
- Wehmeyer M, Obermski S. 2010. Intellectual Disabilities. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online: http://cirrie.buffalo.edu/encyclopedia/en/article/15/
- Pipan M. 6/2012. Intellectual Disability: Definition, Classification, and Systems of Supports 11th ed. Journal of Developmental & Behavioral Pediatrics: Volume 33-Issue 5 p 356 doi 10.1097/DBP.06013e31825e2492
