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People with intellectual disabilities (IDs) often face challenges in accessing dental care, including difficulties communicating, behavior management, and a fear of dental procedures. Here are strategies that work for me when treating patients with IDs.
Understanding IDs and dental care
There are more than six million Americans with IDs.1 IDs are developmental disabilities (DDs) present from birth, or that typically develop during the first few years of life, that affect a person's cognitive and adaptive functioning. They limit intellectual functioning, such as problem-solving, reasoning, and learning, and adaptive skills, such as communication, social skills, and daily living and self-care skills.
IDs are typically caused by a genetic or environmental factor and may range from mild to profoundly severe. Those with IDs face challenges in various aspects of life, including education, employment, and independent living. They often require support and accommodation to achieve their full potential.
It’s common for patients with IDs/DDs to have dental issues, including congenitally missing teeth, malocclusion, muscle laxity or rigidity, dry mouth, increased plaque, and a high caries proclivity.2 These individuals may also have medical conditions that increase the likelihood of dental issues, such as chronic gastroesophageal reflux or medication-induced dry mouth.
Challenges in providing dental care for those with IDs/DDs are communication issues, behavioral management, fear and anxiety, limited access to adequate care or facilities, and legal and ethical considerations. They have difficulty communicating their dental problems, needs, or concerns, which can lead to misunderstandings, misdiagnosis, or inadequate treatment. They often exhibit challenging behaviors, such as resistance, anxiety, or aggression during dental procedures, which makes it difficult for dental professionals to perform the necessary treatments.
Their fear of dental procedures can be compounded by sensory issues, unfamiliar environments, or previous negative experiences, making it challenging to establish trust and cooperation. They may face barriers to accessing dental care, such as transportation issues, financial concerns, or lack of specialized services, and this leads to untreated dental problems and further complications. They often have underlying medical conditions that can affect their oral health, such as epilepsy or diabetes, which can require special attention during dental procedures, and there may not be facilities close by that can accommodate their needs.
Dental professionals may face legal and ethical considerations while providing dental care to those with IDs/DDs, such as obtaining informed consent, respecting privacy and dignity, and ensuring the safety and welfare of the patient. But offering dental care is crucial to enhance their overall well-being and quality of life.
Strategies for treating dental patients with IDs
I have found the use of visual aids, simple language, and nonverbal communication can lead to a more successful visit. Learning some basic sign language skills is also helpful. Behavior management strategies I use are positive reinforcement, distraction techniques, and sometimes, sedation. Weighted blankets (weight must be no more than 10% of the patient's overall body weight), body positioners for the dental chair, and pressure vests can also help calm anxious and fearful patients.
Accommodating their physical needs includes wheelchair accessibility, positioning, and anesthesia management. Positioning devices such as knee bolster pillows and wedge pillows keep the patient up in the dental chair in a comfortable body position. Mouth props, sponges for the saliva ejector to make it softer on the oral tissue, and a high-volume evacuation (HVE) with perforations to prevent the drawing up of the buccal mucosa are valuable items to have available for these appointments.
To prepare for the dental appointment, include caregivers in talking up the appointment to the patient ahead of the visit. “Get to know you” appointments, in which little to no treatment is performed, have been a hit with my patients. Desensitization, which is typically done at home by the caregiver using a toothbrush or spoon to help the patient adjust to tools in their mouth, can also be helpful. Additionally, the caregiver can check the patient's mouth multiple times a day and ask them to open wide. This will help with desensitization.
Adaptation of dental procedures, including shorter appointments when appropriate, modification of instruments, and alternative treatment options will be necessary. For the first few appointments, schedule longer appointment times so you have enough time to work with the patients' fears and needs and to establish rapport.
Case study of ID/DD dental patient
This case study involved a 33-year-old male patient with hearing loss, loss of vision, who cannot speak, and who has both DD and ID. He understands some basic sign language. He has muscle rigidity in his oral cavity with limited opening. Due to sensory issues, he eats only a soft diet and is not compliant with his guardian's oral home care.
The patient has increased anxiety and agitation when he must see multiple providers. Therefore, he’s scheduled consistently with one dental hygienist. He’s become comfortable with his hygienist and trusts her. He can hear just enough to understand basic phrases such as “come with me,” “look at me,” and “open your mouth.” He does not/cannot communicate back but typically obeys a command. The hygienist has learned some basic sign language to communicate with him.
Due to his soft diet and difficulty with home care, he has an excessive buildup of dental plaque and supragingival calculus on the buccal aspect. Even under sedation, his mouth rigidity cannot be overcome. Therefore, a mouth prop is used during the prophylaxis procedure. A curette is used for scaling instead of a sickle as he tends to move his head frequently during the procedure and the sickle becomes dangerous to use.
The mouth prop allows the hygienist to scale, polish, and floss each side completely. The patient's sensory issues cause him to bring his lips in and tighten them while the practitioner is working. On his right side he tolerates the mouth mirror well but on his left side he does not. The hygienist uses her fingers for retraction and with this he relaxes and does not squeeze his muscles tight. This allows for better access to the posterior area of the oral cavity.
Intraoral x-rays are difficult, but pano bitewings, a complete panoramic x-ray, and selective periapical x-rays are taken as prescribed by the dentist. Intraoral photos are taken to communicate his oral condition with his caregivers. His recare appointments are recommended at shorter frequencies to better control his oral health.
It was a process to get the patient where he is today. Before, only brushing was possible and that was difficult. As the hygienist has worked with the patient, trust has been established, and he’s become comfortable with her. With these strategies in place and trust built, as well as home-care education for caregivers, this patient has not had tooth decay frequently despite his elevated caries risk.
Caring for ID/DD patients
Treating dental patients with IDs requires a thoughtful and individualized approach. By using strategies such as effective communication, behavior management, accommodation of physical needs, preparation, and adaptation of dental procedures, dental professionals can provide high-quality care to those with IDs/DDs, improving their oral health and overall well-being. Dental professionals can collaborate with caregivers and other health-care professionals to ensure comprehensive care for these patients.
References
1. Addressing gaps in health care for individuals with intellectual disabilities. Centers for Disease Control and Prevention. October 15, 2019. Accessed April 23, 2023. www.cdc.gov/grand-rounds/pp/2019/20191015-intellectual-disabilities.html
2. Developmental disabilities & oral health. National Institute of Dental and Craniofacial Research. Accessed April 23, 2023. www.nidcr.nih.gov/health-info/developmental-disabilities
Editor's note: This article appeared in the April/May 2024 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
