Oral Health, Nurses and Patients with Developmental Disabilities

Abstract

Increasing numbers of people with intellectual, developmental and other disabilities reside in our communities. They require a vast array of services provided by local health care practitioners. A working relationship between nurses and dentists could increase the availability and accessibility of dental services for patients with special needs, as well as alert families and others responsible for their care to the importance of oral health as an integral component of total health.

Keywords: developmental disabilities , intellectual disabilities , oral health , nursing care

The favorable outcome of collaborative efforts by nurses and dental personnel to prevent and treat oral diseases has been reported repeatedly in the literature^{1, 2}. The initial physical examination of clients and subsequent follow-up contacts offer nurses a unique opportunity to explore a wide range of services - including dental care - that youngsters and adults need. Numerous reports in the literature detail the role nurses can and do play in the care of patients with special health care needs (individuals with intellectual disabilities, developmental and other disabilities)³. Much of the literature places particular emphasis on the opportunity for nurses to develop health promotion and self-care programs to increase the independent living capacity of this population in community-based group homes and personal home environments⁴.

Yet an extended Medline search of three decades of literature produced not one entry on increasing nurse practitioner awareness of the dental needs of individuals with special health care needs.

The U.S. Surgeon General's Report, "Oral Health in America," provides both a clarion call and a clearer picture of the significant need for dental services for particular population groups: the poor, minority populations and individuals with intellectual, developmental and other disabilities⁵. Surely, nurses can help!

NUMBERS AND CHANGING SETTING FOR CARE

In the United States in the late 1960s, there were more than a quarter of a million individuals with intellectual, developmental and other disabilities in state institutions. During the following decades, the number of residents decreased by more than 76 percent^{6, 7}. Changing social policies, favorable legislation for people with disabilities, and class-action legal decisions that delineated the rights of individuals with disabilities led to deinstitutionalization, the establishment of community-oriented group residences and enhanced personal family residential settings, and closure of many large, state-run facilities. These changes have impacted health care significantly.

Most community residential facilities are too small in size to provide intramural services. As a consequence, health care monitoring can be difficult when delivery of services and health records are disseminated among multiple providers and locations. The success of community-based health programs, therefore, depends on:

• The capacity to organize and maintain the services and health records of these "new" community residents and the increasing number of individuals with special needs in existing community families.
• The ability of nurses and physicians who provide consultation and medical "gate-keeping" services for individuals with special needs to recognize and identify the wide range of needed health services, including preventive and restorative dental care.
• The complex needs of individuals with intellectual, developmental and other disabilities and their families may at times seem to overwhelm the best of intentions and efforts of nurses and family practitioners. Given these realities, is dental care "really that important"? Yes! Maybe more than we think!

DENTAL CARE NEEDS

All too often the reality that oral health is related to the general health and well being of individuals in the general population, as well as to persons with special needs, is overlooked. The lack of dental care or inadequate care can result in a number of health complications. For example, periodontal disease is a contributing factor for cardiac disease, adverse pregnancy outcomes, the rate and severity of bone loss for post-menopausal women and for diabetics (as well as increased difficulties in maintaining blood sugar levels for diabetics), and dental infections leading to the loss of transplanted organs^{5, 8, 9}.

Despite these health risks, no nationwide physical examination studies have been conducted to determine the prevalence of dental disease among the various populations with disabilities. However, a recent national telephone questionnaire survey for families with children with special needs found that "the [health] service most commonly reported as needed but not received was dental care..."¹⁰.

Numerous local and regional reports do provide a general understanding of the oral health requirements of individuals with special needs. People with disabilities have significantly higher rates of poor oral hygiene and periodontal disease than the general population: "Eighty-five to 90 percent of people with Down Syndrome have periodontal disease..."¹¹. Increasing evidence relates periodontal disease and ischemic stroke and cardiovascular disease^12-14. Furthermore, the range of caries (tooth decay) rates varies widely among people with disabilities, and, overall, the caries rates are significantly higher among people with disabilities than among those without disabilities. Much of the variation in the rate of caries stems from where people with disabilities reside (i.e., in state institutions where services are generally available vs. community and residential settings where services need to be secured from community practitioners) and the reluctance of community practitioners to provide essential services. This reluctance often results from a combination of limited training and experience, as well as a lack of adequate private dental insurance and government support^{15, 16}.

In addition to the usual range of dental care needs, children and adults with intellectual, developmental and other disabilities often present with numerous and/or advances cases of:

• Baby-bottle tooth decay/early childhood cavities: A child's bedtime or naptime use of a bottle containing juice, milk, formula or any liquid sweetened with fermentable carbohydrates can lead to rampant decay. Its first clinical sign begins insidiously as a whitening/decalcification of the maxillary primary incisors. If the child remains on the nighttime bottle, decay can progress very rapidly.
• Altered salivary flow and tooth decay: Psychotropic medication can decrease salivary flow, resulting in xerostomia (dry-mouth), salivary glands with retrograde infections and possible stone formation, as well as increased rates of dental decay.
• "Placating" tooth decay: Candy bars (and yes, pediatrician-dispensed lollipops) may meet the immediate need to calm and sooth a child, but combined with numerous other contributing factors they may dramatically increase decay rates. In addition, frequent snacks of heavily sugarcoated cereals are also a potential source of extensive tooth decay.
• Malocclusions: A high incidence of functional and esthetic malocclusions exists, resulting from: 1) untoward habit development; 2) absence of a diet that includes rough and coarse food which requires thorough chewing; 3) increased level of unrestored caries; 4) the loss of teeth, tooth structure and lack of space maintenance; and 5) patient management limitations.
• Fractured and nonvital teeth: Resulting from trauma and/or advanced dental decay. Broken and/or darkened teeth are indicators of potential infection and should be monitored and, if necessary, restored.
• Soft tissue complications: Seizure medication (e.g., Dilantin) can cause hypertrophy or overgrowth of the gingival tissue. This can lead to difficulties in mastication and advanced periodontal problems.
• Bruxism: is the grinding or gnashing of teeth and usually is reported to occur while a child or adult is asleep. (Bruxomaniais the involuntary grinding of the teeth that occurs when an individual is awake.) Continued wearing away of teeth can endanger the vitality of the teeth. Individuals with cerebral palsy and/or moderate to severe intellectual disabilities often grind their teeth with great frequency and intensity.

As with all forms of medical and dental services, early intervention is preferable to extensive services at some later date.

HOW CAN A NURSE HELP?

The diversity of services needed by individuals with intellectual, developmental and other disabilities may seem, at times, to overwhelm the parents/guardian, community home mangers, and health professionals responsible for organizing and arranging needed support programs. Yet it is these very same people who continue to single out dental care as the most critical unmet service needed by youngsters and adults with special needs. How, then, can nurses help?

Helping means more than "just" referring patients with special needs for dental care. All too often an oral examination by some non-dental health providers skips from the lips-to-the-tonsils with a notation on the record of "WNL" (i.e., "Within Normal Limits" - which probably should stand for "We Never Looked"). A basic oral examination, an appreciation of the causal factors of dental disease, and an awareness of the fundamentals of preventing dental disease take on added meaning when caring for the seemingly never-ending and often interrelated needs of individuals with intellectual, developmental and other disabilities.

In addition, informing family members, community home managers and others responsible for the well being of individuals with special needs about the related general dental conditions of their wards could alert care givers to underlying causal factors for other unexplained medical difficulties. Indeed, the role of nurses as primary care providers offers a unique opportunity to increase dental services for children and adults with intellectual, developmental and other disabilities.