Neglecting oral hygiene can result in disease, pain, loss of teeth, and difficulties in eating and speaking.
VOL: 101, ISSUE: 06, PAGE NO: 40
Catherine Bernal, MSc, RNLD, is senior lecturer in learning disabilities, Canterbury Christ Church University College
For people with learning disabilities poor oral health can further inhibit social integration and may affect learning capacity (Rawlinson, 2001; Tiller et al, 2001). Pain resulting from such neglect may elicit challenging and self-injurious behaviour in this client group (Rawlinson, 2001; Gates et al, 2000). It is likely too that poor oral health will lead to low self-esteem and negative body image (British Society for Disability and Oral Health, 2001).
Learning disabilities and additional risk
People with learning disabilities require greater attention to oral hygiene (Gates, 2003; Department of Health, 2001a; Lange et al, 2000). This has been confirmed by several research projects (Tiller et al, 2001; Cumella et al, 2000; Gallagher, 1998). There are several reasons for this:
- Many people with learning disabilities have conditions that carry inherent risks to oral health, for example people with Down’s syndrome are likely to breathe more through the mouth, which can compromise oral hygiene and people with cerebral palsy are subject to dental abrasion from gastroesophageal reflux (Gates, 2003);
- Difficulties carers face in meeting the nutritional needs of people with multiple disabilities - which may include the necessity for high-energy food supplements and laxatives - increase the risk of dental caries (BSDOH, 2001);
- Oral hygiene tends not to be given a very high priority in services for profoundly disabled individuals (Griffiths and Boyle, 1993);
- People with severe learning disabilities are frequently prescribed medication in syrup (Franklin, 2002);
- Poor access to oral care, resulting either from factors that inhibit access to generic health care (for example fear, ignorance, lack of appropriate health promotion) or from a misinterpretation of normalisation, which can result in rejection of the medical model of care by health care professionals and subsequent neglect of physical needs (BSDOH, 2001);
- Carers may not have the appropriate skills to maintain oral hygiene (BSDOH, 2001; Tiller et al, 2001), which can be compounded by the behavioural and communication difficulties of service users;
- Difficult physical access to dental services faced by many people with multiple disabilities (BSDOH, 2001);
- The inability of many people with learning disabilities to complain of dental or gingival pain;
- The lack of specialist training for dentists to meet the needs of this client group (BSDOH, 2001);
- Fragmentation of dental services (Rawlinson, 2001).
When considering the practicalities of oral hygiene for this client group, it is important to use the principles of oral hygiene that apply to any child or adult (McGrath, 2003). The main aims are to maintain the comfort and moisture of the mouth and keep it free from infection using a soft toothbrush and paste. Before commencing oral care plans, clients should be assessed for their level of hydration and their oral health status. Any dentures will require cleaning at least once a day, and teeth should be brushed at least once a day (McGrath, 2003).
There is a need for the development of specialist skills and services to improve oral health for people with learning disabilities. One study (Rawlinson, 2001) has already made clear the need for community learning disability nurses to work with carers and specialist dental services to monitor the oral health of people with learning disabilities. This role dovetails effectively with that of the ‘health facilitator’ called for in Valuing People (DoH, 2001a) (Box 1). A health facilitator should have been appointed for every person with a learning disability by June 2005.
While such strategic developments are welcome, they do little to enhance the practical skills of health care professionals working with people with learning disabilities and their carers (BSDOH, 2001; Rawlinson, 2001).
Gates (2003) has indicated that the oral hygiene of people with more severe disabilities, particularly those with cerebral palsy, may be compromised by the bite reflex. This can be minimised by using simple desensitisation measures before brushing such as gently stroking around the mouth and adjacent facial areas, or possibly by using an electric toothbrush.
Clients who are highly dependent may also dislike having their teeth brushed, an issue which may demand considerable creative resources on the part of the health care team. These may include quite sophisticated measures (for example the application of behaviour modification, or gentle teaching) to reduce the person’s resentment (Gates et al, 2000).
The effects of certain medications prescribed to people with learning disabilities should also be considered. For example, phenytoin, one of the ‘older’ anti-epileptic drugs, is still commonly prescribed to people in this client group, and has been associated for some years with the development of both gingivitis and gingival hyperplasia (Gates, 2003). If it is not possible to prescribe one of the newer anti-epileptic drugs, which generally have fewer potential side-effects, particularly scrupulous attention should be given to oral health and the client’s dentist be made aware of the prescription.
Clients with profound disabilities are also more likely to be prescribed medication in syrup form, due to either swallowing difficulties or dislike of tablets (Manley et al, 1994). Carers and prescribers need to be aware that many such medications are now available in sugar-free liquid forms.
Bearing in mind the challenges of maintaining dental hygiene in this particular client group, carers might find the use of plaque-disclosing tablets particularly helpful in monitoring the success of their cleaning techniques (Gates, 2003; Lange et al, 2000).
In 2001 authoritative guidelines for the oral health care of people with learning disabilities were published (BSDOH, 2001). They are based on research with people with learning disabilities and their carers, and include sections on the professional practice of dentistry and dental hygiene, as well as good practice advice for individuals and their carers in the home environment.
These highly practical guidelines offer advice on overcoming specific problems in oral care and make suggestions regarding the appropriate response to bite reflex, tongue thrust and oral hypersensitivity, and dealing with reduced or absent cooperation. The BSDOH suggests repeated short brushing sessions for intolerant clients, the use of distractions such as music and videos, and it points out the benefit of two carers - one able to support the person and one holding the person’s hands to prevent interference in the brushing process (Gates et al, 2000).
The guidelines also advise on sedation and general anaesthesia (GA) in dental treatment for people with learning disabilities. It is unfortunate, however, that while the guidelines discuss the indications for GA at some length, no corresponding criteria are offered for the use of sedation. It is clearly a matter for the individual and/or the health facilitator to discuss with the relevant practitioner.
An obvious concern regarding sedation or GA for this client group is the issue of consent. The BSDOH emphasises the need to obtain informed consent where this is possible, and refers to the practitioner’s legal duty of care where it is not. However, health care professionals working with people with learning disabilities whose capacity to consent is in question will require a more detailed framework. This can be found in the booklet Seeking Consent: Working with People with Learning Disabilities (DoH, 2001b).
The BSDOH guidelines set out advice to service users themselves, using accessible language (p41, Box 2). The lack of dental health promotion materials for this client group has already been noted, and these recommendations need to be made available to clients by health care professionals working with them. These will often be health facilitators (and community learning disability nurses) as set out by the Department of Health (2001a).
The needs of carers
In the current context such advice will be useful only to a proportion of the growing population of people with severe, profound and multiple disabilities (Gates, 2003). There remain many whose disabilities prevent access to health promotion of this type and whose oral health is entirely in the hands of their carers.
It has been questioned whether these carers would be sufficiently skilled (Franklin, 2002; BSDOH, 2001; Lange et al, 2000), and improvements in staff development and training have been called for (Rawlinson, 2001). While it is disappointing that there was no specific reference to improving the oral health of people with learning disabilities in the recent white paper (DoH, 2001a), the BSDOH guidelines and its advice to carers should help to improve the situation (Box 3).
The BSDOH guidelines make further recommendations for carers. They include the advice that all people with learning disabilities should be registered with a dentist and should be assisted to visit regularly, that all clients should have an oral care plan drawn up in partnership with their carers and dental team, that carers should seek professional help and advice to carry out daily oral care, and that individual carers should not decide to discontinue oral hygiene practice without consulting with the health care team.
Unmet dental health needs in this population are still being reported (Malstrom et al, 2002), and it would appear that dissemination and/or adoption of the BSDOH guidelines has been slow. Therefore, every practitioner with an interest in the holistic well-being of people with learning disabilities should attempt to raise awareness both of good practice in oral hygiene and the existing advice upon which it may be based.
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:
- Understand the problems people with a learning disability have with oral hygiene;
- Know why people with a learning disability are at particular risk;
- Be familiar with measures for maintaining oral hygiene among this client group;
- Know the best advice oral hygiene advice to give this client group.
Use the following points to write a reflection for your PREP portfolio:
- Describe why you read this article and how it is relevant to your practice;
- Summarise the main points of the article;
- Identify a fresh piece of knowledge the article has taught you;
- Consider how you will use this knowledge in your future practice;
- Explain how you intend to follow up what you have learnt.