People with developmental disabilities are at an increased risk for both dental malformations and dental diseases. While dental caries and periodontal disease, the primary dental diseases, are entirely preventable in people with severe developmental disabilities, dental problems are still common. The public in general, including individuals with developmental disabilities and their caregivers, do not place high priority on or understand the importance of good oral health, the nature of dental diseases as infectious diseases, the consequences of poor oral health, or the procedures necessary to maintain oral health. While general health and social service professionals (physicians, nurses, nurse practitioners, social workers, etc.) can play an important part in educating individuals with developmental disabilities or their caregivers, they often fail to do so for a variety of reasons. Some of these reasons include difficulty in finding oral health professionals who accept public insurance and have the expertise working with people with special needs, the historical absence of a required oral health assessment in many early start or medically-focused programs, and an insurance and health care system that has separated the mouth from the body’s total health and well-being.
Other reasons for increased dental diseases include underlying disorders, congenital infections, malformations of the mouth or jaw, behavioral problems, differences in diet and eating patterns, and the use of certain medications. Oral health is important for adequate nutrition, speech, and aesthetics. Despite the increased risk of disease and the importance of oral health, dental care has historically been one of the greatest unmet needs of people with developmental disabilities.
It is important for the primary care physician, nurse, and social worker to play an active role in preventing dental problems and making referrals for oral health. Often it is the nurse or physician who first examines an infant as risk. This “early start” evaluation can be the first and only intervention and referral for an oral health exam. Recently, the American Academy of Pediatrics recommended that every infant have an oral exam by age 1.
By being familiar with the dental problems associated with certain developmental disabilities, primary care physicians and nurses will be able to recommend preventive measures, monitor for the onset of problems, make appropriate referrals to oral healthcare providers, and alert oral healthcare providers of the increased risk for certain dental problems.
Difficulty brushing teeth and flossing can lead to poor dental hygiene. People with physical disabilities may be more trauma-prone (especially those with epilepsy and motor dysfunction syndromes), which increases the risk of tooth damage from falls.
Phenytoin (Dilantin) is likely to cause gingivial hyperplasia (overgrowth of gums), which makes the gums more vulnerable to infection, trauma, and bleeding. Medications, including those used to address muscle control or psychoses, may decrease the production of saliva (xerostomia) and increase the risk of dental diseases. Excessive syrup medications can cause tooth decay.
Cleft lip and palate and many other conditions may result in hypodontia (absence of one or several teeth); enamel hypoplasia; extra teeth; malocclusion; and cross bite, which can lead to feeding difficulties and difficulty removing plaque.
Abnormal function of the tongue, lips, and cheek may adversely affect the mouth’s natural cleaning patterns and alter the natural guidance of teeth into the proper alignment as they erupt. Poor suck may affect feeding. Abnormal patterns of swallowing may cause food to linger in the mouth, increasing the risk for tooth decay. Pouching (holding foods in mouth) increases bacteria that may cause tooth decay and gum disease.
Gastroesophageal reflux disease introduces higher levels of acids to the mouth, which can damage tooth enamel and lead to tooth decay.
Low fluid intake and pureed diets reduce the natural cleansing action of the tongue. Soft diets rich in carbohydrates can increase tooth decay. Inadequate nutritional intake can lead to dental and other health problems. Tube-feeding can create calculus deposits on the teeth.
Bruxism (tooth grinding) is very common among people with developmental disabilities, and may lead to enamel and dentin abrasion, fracture, abnormal mobility of the teeth, or temporomandibular joint disorder. Self-injurious behavior (head banging, gum picking, lip biting) may lead to tooth loosening or fracture and gingival disease. Excessive drooling or tongue thrusting decreases the amount of saliva in the mouth, which is necessary for natural cleansing. Pica may introduce sharp, toxic, or otherwise harmful materials to the mouth.
Caregivers often focus on health and daily living needs but neglect the importance of dental care. Children with disabilities may feed from bottles longer and more often, which can lead to malocclusion and increased tooth decay as liquids pool around the teeth and the teeth are exposed to fermentable carbohydrates for long periods of time.
The American Academy of Pediatrics (AAP) released in May 2003 the recommendation that every child (infant) needs an oral health risk assessment at six months of age. Certainly by the age of 1, an oral health risk assessment is needed. Because pediatricians are more likely to encounter new mothers and infants than dentists, the AAP recommended physicians to be aware of risk factors for early childhood tooth decay and make appropriate decisions regarding interventions and referral.
Every infant, toddler, child, teen, and adult with a developmental disability needs a customized oral health plan. The complete range of preventive strategies such as decreased exposure to fermentable carbohydrates, increased use of fluorides, use of Xylitol products, etc., should be considered. This oral health plan should include recommendations for sealants and mouth guards as needed. Also, it should address any behavioral, physical, and/or informational barriers that individuals with disabilities and their caregivers may encounter.
Many persons with developmental disabilities will not feel comfortable having their mouths examined or worked on, especially if this experience is new to them. If a patient will not cooperate with a dental exam or procedure, encourage his or her caregiver and/or dentist to use desensitization by starting very slowly and gradually increasing the level of intensity.
A restraint should only be used when absolutely necessary and should not cause injury or trauma. It is important to obtain consent for dental exams and procedures. As needed, recommend restraints in the following order:
Return to the index for the following documents that contain specific Oral Health Care Considerations:
Dajani, Adnan S. MD, et al. (1997). Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Journal of the American Dental Association, 128(8), 1142-1151.
Gabre, P and L Gahnberg. (1997). Inter-relationship Among Degree of Mental Retardation, Living Arrangements, and Dental Health in Adults with Mental Retardation. Special Care in Dentistry, 17(1), 7-12.
Helpin, M,. Rosenburg, H. (1996). Dental Care:Beyond Brushing and Flossing. In M. L. Batshaw (Ed.), Children with Disabilities (4th ed., pp.463-656). Baltimore: Paul H. Brookes
Waldman, HB, et al. (1998). Dental Care for Children with Mental Retardation: Thoughts about the Americans with Disabilities Act. ASDC Journal of Dentistry for Children, 65(6), 487-491.
Batshaw, Mark L., Perret, Y.M. (1997). Children with Disabilities. Baltimore: Paul H. Brookes.
Waldman, H.B., Perlman, S.P. (2002). Providing Dental Services for Persons with Disabilities: Why is it so Difficult? Mental Retardation, 40,(4) 330-333.
Lewis, C., Robertson, A., Phelps, S. (2005).Unmet Dental Needs Among Children With Special Health Care Needs: Implications for the Medical Home. Pediatrics,116(3), 426-2431.
California Department of Developmental Services. (1997). Dental Care Concerns for Special Needs Persons. Wellness Digest, 1(1).
Pearlman, Joel DMD. (1989). In: Developmental Disabilities: Delivery of Medical Care for Children and Adults. Eds: Rubin, I. Leslie and Allen C. Crocker. Philadelphia: Lea & Febiger, pp. 320-332.
Smith Consultant Group and McGowan Consultants. (1998). Ed: Michele Ligon Snyder, MS. “Dental Care.” Health and Wellness Reference Guide. Neri Productions, State of Tennessee Commission on Compliance (July), pp. 43-44.
Southern Association of Institutional Dentists. (2001). Module 7: Oral Manifestations in Genetic Syndromes with Mental Retardation. Modules. Retrieved on June 7, 2006 from http://saiddent.org/modules/15_module7.pdf
National Oral Health Information Clearinghouse
Oral Conditions in Children with Special Needs
A Guide for Health Care Providers
Southern Association of Institutional Dentists
University of Florida
College of Dentistry
Department of Pediatric Dentistry
Oral Health Care for Persons with Disabilities
University of the Pacific
School of Dentistry
Center for Oral Health for People with Special Needs
American Academy of Pediatric Dentistry, 312-337-2169
Cleft Palate Foundation, (919) 933-9044,
American Dental Association, 312-440-2500,
American Dietetic Association, 800-877-1600,
California Dental Association, 800-736-8702
California Department of Developmental Services, 916-654-1690,
California Foundation of Dentistry for the Handicapped, 916-498-6176
California Regional Centers, 916-654-1958,
Dentistry for the Disabled Child and Adult, 314-725-3844
National Foundation of Dentistry for the Handicapped, 303-534-5360
National Oral Health Information Clearinghouse, 301-402-7364, TTY 301-656-7581,
Rural Northern California Dental Program for Persons with Disabilities, 415-929-6426
Special Athletes, Special Smiles, 617-638-4891
Special Care Dentistry Association, 312-527-6764
Special Olympics Special Smiles,
Theodore A. Kastner, M.D., M.S.
Felice Weber Parisi, M.D., M.P.H.
Robin L. Hansen, M.D.
Patrick J. Maher, M.D.
Funded by a grant from the California Department of Developmental Services
For more information, contact:
Center for Health Improvement
1330 21st Street, Suite 100
Sacramento, CA 95814
This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.
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