Dental Care

INTRODUCTION

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.

Types of Dental Problems

Dental Decay (caries and cavities)

Cause: Dental caries is understood to be a balance between factors that cause dissolution of tooth structure (demineralization) and factors that result in repair of tooth structure (remineralization). Acid dissolution of tooth structure (demineralization) is caused by a combination of plaque bacteria (primarily streptococcus mutans), extended exposure of plaque to fermentable carbohydrates (primarily sucrose), and decreased buffering capacity of saliva (from xerostomia or mouth breathing). Tooth structure may be repaired (remineralized) by a combination of removal of plaque; use of antimicrobial agents such as Chlorhexidine and Xylitol; use of fluoride containing water, varnishes, gels, and rinses; and periods of time with no fermentable carbohydrate ingestion.
Possible Complications: pain, localized infection, regional infection and cellulites, sepsis leading to death, decreased mastication, loss of self-esteem, and difficulty finding employment
Prevention: The objective of caries prevention is to tip the caries balance in favor of remineralization. Preventive practices include
Daily plaque removal by tooth brushing and flossing, particularly removing plaque before meals
Use of fluoridated water and toothpaste
Dietary counseling including reduction in fermentable carbohydrate (sucrose) ingestion and especially confining fermentable carbohydrate ingestion to meal times
Avoidance of prolonged use of bottles containing fermentable carbohydrates and instructions to caregiver to never put a child to sleep with a bottle containing fermentable carbohydrates
Use of gum, mints, or foods containing Xylitol as the primary sugar to reduce caries
Use of antimicrobial (Chlorhexidine) mouth wash, or spray, as an adjunct for some individuals with rampant caries and gingivitis
Professionally applied fluoride and sealants

Treatment: dental sealants, dental restorations (fillings and crowns), extraction of unrestorable teeth, and replacement of missing teeth with removable or fixed prosthetic appliances

Periodontal (Gum) Disease

Signs or symptoms: red, swollen, or bleeding gums; loose teeth
Cause: gingival (gum) inflammation due to byproducts of bacterial breakdown of fermentable carbohydrates made possible by poor dental/oral care and diet, leading to loss of attachment of gingival tissues to teeth and then inflammatory bone loss
Influencing factors: poor oral hygiene procedures exacerbated by malformed or poorly arranged teeth, bruxism, poor health, medication side effects
Prevention: daily plaque removal by tooth brushing and flossing, particularly removing plaque before meals; use of fluoridated water and toothpaste; dietary counseling including reduction in fermentable carbohydrate (sucrose) ingestion and confining fermentable carbohydrate ingestion to meal times; correction of malocclusion

Dental Injury

Signs or symptoms: chipped tooth, tooth fractures; tooth loss
Cause: chewing hard items, falls or blows to the mouth
Treatment: tooth repair or replacement if possible; check for possible fracture of facial bones and neurological injuries

Signs and Symptoms of Dental Problems

Physical Signs

Pain or discomfort of mouth or jaw
Bleeding gums or blood on the toothbrush
Headache
Unusual mouth odor
Discoloration or other unusual appearance of teeth

Behavioral Signs

Refusal to eat or drink
Hand or fingers in mouth
Head banging or rocking
Aggressive behavior, hitting, biting

DENTAL ISSUES IN DEVELOPMENTAL DISABILITIES

Causes or Influencing Factors

Physical disabilities

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.

Medications

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.

Congenital anomalies

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.

Oral motor disorders

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.

Common secondary conditions

Gastroesophageal reflux disease introduces higher levels of acids to the mouth, which can damage tooth enamel and lead to tooth decay.

Diet differences

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.

Common behaviors

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.

Other

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.

Dental Concerns in Specific Syndromes

Angelman Syndrome

Small, widely spaced teeth
Excessive drooling, chewing/mouthing
Swallowing difficulties

Cerebral Palsy

Enamel hypoplasia
Poor oral motor control (swallowing difficulties, tongue thrusting)
Malocclusion
Bruxism
Temporomandibular joint (TMJ) disorder
Difficulty brushing and flossing

Cornelia de Lange Syndrome

Micrognathia (small jaw)
Cleft palate (20%)
Thin, down-turned lips
Microdontia
Delayed tooth eruption
Widely spaced teeth

Down Syndrome

Delayed eruption of teeth
Hypodontia
Malocclusion
Tooth dysmorphology
Bruxism
Impaired masticatory function
Small maxilla and mouth resulting in mouth breathing andwith protruding tongue
Periodontal disease (60-100%)

Epilepsy

Gingivial hyperplasia from phenytoin (Dilantin)
Increased risk of dental injury from falls

Fetal Alcohol Syndrome

Robin sequence (small mandible with large recessed tongue)
Probable need for orthodontic treatment

Fragile X Syndrome

Hand biting

Klinefelter (XXY) Syndrome

Prognathism (projection of the jaw)
Taurodontism
Large permanent tooth crowns

Neurofibromatosis Type 1

Macroglossia (caused by oral neurofibromas [tumors])
Hyperplasia (overgrowth) of soft and oral tissues
Malpositioned teeth
Wide inferior alveolar canals
Enlarged fungiform papillae

Prader-Willi Syndrome

Dental caries
Enamel hypoplasia
Malocclusion
Gingivitis
Microdontia
Xerostomia (mouth dryness due to decreased salivation)
Calculus (calcium deposits on teeth)
Arched palate
Viscous, bubbly saliva

Rett Syndrome

Bruxism

Spina Bifida

Swallowing difficulties, Arnold-Chiari malformation

Trisomy 18

Robin sequence
Cleft lip/palate
Swallowing difficulties

Tuberous Sclerosis

Dental pits
Gum fibromas
Thinly enameled teeth
Tooth dysmorphology

Turner Syndrome

Micrognathia (small jaw)
High arched palate
Malocclusion
Premature eruption of permanent molars

Williams Syndrome

Small or missing teeth
Malocclusion
Probable need for orthodontic treatment

XYY Syndrome

Shovel-shaped lateral incisors
Large teeth

MEDICAL MANAGEMENT CONSIDERATIONS

Preventive Dental Care

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.

Referral to Dentist

Recommend and refer for an oral health risk assessment at six months of age or at least by age 1 and for the development of a customized oral health care plan, preferably to a dentist with expertise and interest in treating people with disabilities.
Request a copy of the patient’s Oral Health Care Plan.
Provide dentist with complete, up-to-date medical history, including doses and frequency of previous and current medications.
Discuss with the patient and caregiver what will happen at dental visits to decrease anxiety.
Refer for behavior modification therapy or sedation to reduce anxiety about going to the dentist, as needed.
Recommend dental exams and cleanings twice per year or more frequently if indicated.

At-Home Care

Establish good daily oral hygiene procedures including plaque removal by brushing and flossing.
Modify usual methods of brushing/flossing teeth for individuals who cannot perform these procedures in the usual manner.
If patient will not cooperate with brushing, teach caregiver to use desensitization by starting with some wet gauze or a washcloth on the mouth and gradually moving to a soft, dry toothbrush, then a wet toothbrush, and finally a toothbrush with toothpaste.
Modify toothbrush, use specially designed toothbrushes or floss holders with modified handles to facilitate grasping. A toothbrush or floss holder handle can be modified to make it easier to grasp by pushing the handle through a rubber ball or by attaching the handle to a bicycle grip with plaster of Paris.
Instruct caregivers to position the individual on a couch with their head in the caregivers lap to assist the individuals needing help to remove plaque. Use a lightly moistened brush without toothpaste and use a floss holder for patients who cannot rinse/expectorate or perform these procedures themselves.

Promote diet that does not increase the risk of dental decay.
Consider diet counseling for a patient with significant tooth decay. Consider diet consistency and sugar content of liquid medications.
Avoid prolonged use of bottles containing fermentable carbohydrates and provide instructions to never put a child to sleep with a bottle containing fermentable carbohydrates.
Use fluoridated water and toothpaste. Recommend daily fluoride tablets or drops if water supply does not contain recommended amount of fluoride. It is known that the primary effect of supplemental fluoride is topical and therefore fluoride tablets should not be used.
Use gum, mints, or foods containing Xylitol as the primary sugar to reduce caries.
Use antimicrobial (Chlorhexidine) mouthwash or spray as an adjunct for some individuals with rampant caries and gingivitis.

Medications

Use an alternative to Dilantin if possible.
Recommend rinsing the mouth with water or brushing after each dose of medication.
Recommend sugar-free medications when possible.

Diet and Nutrition

Refer to nutritionist for healthy diet and sugar limitation.
Encourage chewing activity, even when soft foods are eaten.
Encourage weaning from bottles as soon as possible. Avoid prolonged use of bottles containing fermentable carbohydrates and instruct caregivers to never put a child to sleep with a bottle containing fermentable carbohydrates.
Recommend foods with texture if possible.
Advise caregiver to help patient avoid pouching by inspecting the mouth after giving food or medications and giving liquid medications rather than pills.

Other

Consider an occlusal splint at nighttime or behavior modification to control bruxism.
Recommend therapy to achieve lip closure, as needed.
Recommend behavior modification or a mouth guard for self-injurious behavior.

Dental Treatment

Desensitization

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.

Use a gradual introduction to new dental procedures.
Proceed slowly.
Use positive reinforcement, verbal praise, and reassurance.
Minimize distractions.
Use short explanations and simple language.
Take time to present information.
Reinstruct/re-explain information.
Consider the individual’s social age.
Teach activities rather than concepts.
Demonstrated oral hygiene procedures.
Allow the individuals to practice procedures.
Use consistency (i.e., same practitioners, same room/chair for each visit)

Restraints

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:

Mild restraint
Mouth props
Nitrous oxide
Oral premedication
Intravenous sedation
General anesthesia

Surgical Procedures

Ensure that patients with congenital heart disease receive antimicrobial prophylaxis before dental procedures
Consider surgical correction of gingival hyperplasia (overgrown gums) as a result of phenytoin
Refer for surgical correction of cleft lip and palate at age 2-3 months
Consider bone grafting to enhance jaw size and dental arch stability

Return to the index for the following documents that contain specific Oral Health Care Considerations:

Cerebral Palsy
Down Syndrome
Mental Retardation with Unknown Etiology
Mood Disorders (Depression and Bipolar Disorder)
Schizophrenia and Other Psychoses

REFERENCES

Peer-reviewed Journal Articles/Academies

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.

Special Interest Groups/Other Publications

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

RESOURCES FOR ORAL HEALTH CARE PROVIDERS

National Oral Health Information Clearinghouse

Oral Conditions in Children with Special Needs

A Guide for Health Care Providers

http://www.nidcr.nih.gov/HealthInformation/SpecialCareResources

Southern Association of Institutional Dentists

http://saiddent.org/modules.asp

University of Florida

College of Dentistry

Department of Pediatric Dentistry

Oral Health Care for Persons with Disabilities

http://www.dental.ufl.edu/Faculty/Pburtner/disabilities/Default.htm

University of the Pacific

School of Dentistry

Center for Oral Health for People with Special Needs

http://www.cfoh.org

Community Programs

http://dental.pacific.edu

RESOURCES FOR FAMILIES

American Academy of Pediatric Dentistry, 312-337-2169

http://www.aapd.org

Cleft Palate Foundation, (919) 933-9044,

http://www.cleftline.org

American Dental Association, 312-440-2500,

http://www.ada.org

American Dietetic Association, 800-877-1600,

http://www.eatright.org

California Dental Association, 800-736-8702

http://www.cda.org

California Department of Developmental Services, 916-654-1690,

http://www.dds.ca.gov

California Foundation of Dentistry for the Handicapped, 916-498-6176

California Regional Centers, 916-654-1958,

http://www.dds.ca.gov/rc/RCInfo.cfm

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,

http://www.nidcr.nih.gov/HealthInformation/SpecialCareResources

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

http://www.scdonline.org

Special Olympics Special Smiles,

http://www.specialolympics.org/special+olympics+public+website/english/initiatives/healthy_athletes/special+smiles/default.htm

ADVISORY COMMITTEE

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.

PUBLICATION INFORMATION

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

(916) 901-9645

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.