Periodontal treatment in patients with learning disabilities part 1: prevention

Medical barriers

Patients with learning disabilities are 2.5 times more likely to have medical problems than the general population.²⁰ These may be part of a syndrome or exist separately and may directly or indirectly impact upon their oral hygiene and host response.

Those conditions that have a significantly increased prevalence in this group include:

The influence of these conditions on the periodontal health of patients is vast.

Patients with motor abnormalities and physical impairments will directly face difficulties in performing oral hygiene care procedures due to limited manual dexterity and impaired muscle co-ordination (Figures 1, 2 and 3).¹⁷

Cognitive disturbances such as dementia, in conjunction with an already existing learning difficulty, may significantly compromise the quality and frequency of oral hygiene care possible by the individual, accounting for a high proportion of tooth loss (Figure 4).^22,23

Those with complex medical conditions requiring regular and multiple hospital appointments may consider oral health low on their priority list when compared to their other more pressing conditions and oral health professionals may compete with medical professionals for the patients' and care-givers' time and efforts.

Although no specific data is available for the prevalence of diabetes in the UK amongst people with learning disabilities, increased rates have been reported in population-based studies in the Netherlands, USA and Canada.²⁴

A case control study in 2009 suggested that subjects with type 2 diabetes are 2.8 times more likely to have periodontitis and 4.2 times more likely to have significant alveolar bone loss when compared with their controls, with the periodontal disease risk increasing in direct proportion to how poorly controlled glycaemic levels are.²⁵ Chronic states of hyperglycaemia are thought to result in the accumulation of biologically active glycated proteins and lipids, producing an exaggerated inflammatory response and defects in host response.^26,27

Furthermore, a bidirectional relationship between the two conditions has been documented.^26,28,29 Once periodontal disease is established, oral infection is thought to act as a ‘metabolic stressor,’ worsening glycaemic control.^26,29 Oral bacteria and bacterial products may disseminate through the bloodstream from the gingival blood vessels, causing an inflammatory response at remote organ sites, thus worsening the situation further.^26,29 Periodontal treatment has been shown to have a positive effect on glycaemic control, improving it in type 2 diabetic patients for at least 3 months.

Education regarding the importance of daily glycaemic control monitoring is crucial and, in the case of poor control, communication with the GMP must be made for appropriate further measures.

Although an altered immune response is not a requisite amongst those with learning disabilities, significant immune defects have been associated with certain groups, most notably Down's syndrome.³⁰ Compared with other intellectually impaired subjects, those with Down's syndrome are reported to experience the greatest prevalence and severity of periodontal disease, even when oral hygiene levels, degree of intellectual impairment and environmental conditions are similar to other groups.³¹ Immune defects are thought to include reduced neutrophil and monocyte chemotaxis, impaired neutrophil phagocytosis, reduced T-lymphocyte counts and immature T-lymphocytes.³⁰

When considering the increased incidence of diabetes in learning disability patients, these additional immune defects may cause significant immunosuppression in those with Down's, thus reducing the threshold not only for chronic periodontitis to develop, but also aggressive periodontitis and necrotizing ulcerative periodontitis (Figure 5).^32,33,34

The stress of coping with serious medical conditions can further reduce an individual's immune response, potentiating a decrease in secretory IGA, circulating IgG, impairment of T-lymphocyte function and natural killer cell cavity.^35,36 Depression and psychiatric disorders are also common-place amongst this group, being three times higher than in those without learning disabilities, producing similar immunological responses to stress and a loss of interest in self care.³⁷ Specifically, Down's syndrome, Klinefelter's syndrome, as well as those with autistic, hyperkinesis and conduct disorders are reported to develop greater genetic susceptibilities for depression.^38,39 As well as medical co-morbidities, social factors such as unemployment, low income, few intimate relationships and stigmatization can fuel this problem.³⁹

Amongst the health professionals with whom these individuals liaise, dental professionals may be the first point of contact for the diagnosis and management of mental health conditions. Awareness is important and referral to psychology or psychiatric services must be considered.⁴⁰

The medications required for certain conditions can also play an important role, potentially causing alterations in the quality and quantity of saliva produced, thus leading to dry mouth and increased plaque and food retention.⁴¹ When considering the high prevalence of epilepsy within this group, phenytoin may be part of a patient's drug regimen, increasing gingival overgrowth risk and compromising oral hygiene further.⁴²

This may be further exacerbated by the mouth-breathing habits of individuals with certain syndromes due to variances in nasal anatomy, palatine and pharyngeal tonsils (Figure 6).⁴³

Dysphagia has been identified by The National Patient Safety Agency (2008) as one of the five key risk areas in patients with learning disabilities, thus promoting further stagnation and affecting self cleansing mechanisms.⁴⁴

In specific cases, such as phenytoin-induced gingival overgrowth, liaison with the patient's general medical practitioner is advisable to discuss potentially alternative medicines. Folic acid supplementation has been reported as an adjunct to reduce this side-effect, however, conclusions are based on small samples and mostly children (Figure 7).^45,46

Carer barriers

Those with learning disabilities have an impairment of intelligence. This may reduce their ability to understand preventive advice, the importance of oral health and to learn the skills needed to perform adequate oral hygiene on a daily basis.¹ As such, many must rely on care-givers for assistance.⁴⁷

Carers and parents of people with learning disabilities often lack the appropriate knowledge, support and training that they require to fulfil the oral health needs of an individual, with as low as 37% in the community being reported to receive any oral health education.^48,49

The severity of a patient's learning disability and his/her reluctance to co-operate with oral hygiene measures may place restrictions on what a care-giver can achieve. Many care-givers often only clean the anterior teeth, and ignore the posterior teeth, being reported to face challenges such as patients not opening their mouth, pushing them away, moving their heads uncontrollably, as well as spitting at, biting, hitting and/or kicking the care-giver.^50,51 Staff turnover is reported to be high, with comfort levels and behaviours largely being defined by the carers' length of training and experience working with this population.⁵¹ It is thus an important factor in assessment (Figure 8).

Professional barriers

Mencap in 2004, followed by an Independent Inquiry in July 2008, highlighted that, despite high levels of unmet need, people with learning disabilities have a much lower uptake of dental services than the general population, with health promotion information being largely inaccessible to them and their carers.^48,49,20 Recent years have seen significant changes in housing, with numerous individuals moving from large institutionalized houses to smaller community residences. Statistically, this has resulted in even greater health inequalities owing to the lack of well-developed community dental services and an increased responsibility upon those with learning disabilities to adhere with dietary advice and seek oral care themselves.^46,1 Additionally, although local policies may exist in specific care homes, no national guidance exists for carers working in nursing and residential homes on effective approaches to promoting oral health, preventing dental health problems and ensuring regular access to dental care. The Department of Health has identified this need and NICE is currently developing a paper in accordance with this.⁵²

On accessing the dental setting, dental teams themselves may not have adequate experience to provide care for people with disabilities, with knowledge of non-pharmacological behavioural management principles rating low for both specialists and non-specialists.^8,53,54 Pharmacological interventions, including sedation techniques or full general anaesthesia, are more likely to be used by specialists to achieve desired care, however, preventive advice and oral hygiene instruction were found to be of low priority in services for profoundly disabled individuals.⁵⁵ Although experienced practitioners can provide conscious sedation to ASA I/II patients in general dental practice, many may feel it inappropriate due to inadequate remuneration for extra clinical time, the need for special facilities and a lack of understanding and specific training in dealing with challenging behaviours and co-morbidities (Figure 9).⁵⁶

Furthermore, despite the assertion that ‘All people with disabilities should have access to NHS primary dental care’, Owens et al discussed that ‘the Steele Report and the JASCD definition of disability taken together could be construed as meaning that all people with disabilities should be cared for by specialist services,’ thus reducing choice and access further.⁵⁷

Although specialist training programmes in Special Care Dentistry are now being developed throughout the country to enhance knowledge and awareness of more vulnerable groups in society, the most appropriate treatment for these patients may still challenge the most experienced clinicians owing to a lack of evidence-based research and difficulties performing research due to issues with ethics, consent, compliance and sample selection.

Behaviour change

It is important to ascertain whether patients have the capacity to understand the disease process fully and their own role in prevention as behaviour change is fundamental to treatment success.⁶⁴ Where cognition is limited, all reasonable steps should be taken to help them understand the problem, including non-verbal communication or information in a more accessible form where appropriate. Those with speech disorders may benefit from language programmes such as Makaton, which uses signs, symbols and drawings as a communication method (Figure 10).

If effective oral hygiene can be achieved with assistance, the help of a carer or family member must be encouraged.⁶⁵ Strategies and techniques that can be used to educate, motivate and facilitate behavioural change in care-givers in order to improve the oral hygiene of people with learning disabilities are not well researched and conclusions are variable. The level of functioning of the patient is considered an important predictor of the degree to which carers may engage in oral health promotion efforts.⁶⁶ Newton and Asimakopoulou found that the best interventions for changing oral health-related behaviour in individuals with periodontal disease was through motivational goal setting, self monitoring and planning.⁶⁷ It is difficult to assume that these interventions can be extrapolated to care-givers. Giving oral health education to carers has been found to be effective at reducing plaque levels,⁶⁸ however, these changes are not sustained without continuous, systematic and individualized preventive care.⁶⁹ Binkley et al specifically piloted oral health strategies that could affect care-givers' self efficacy living in community group homes. They found coaching/reinforcement of advice and quality in-home training demonstrations to be the most positive.⁷⁰ Wang et al, in a systematic review of five studies, suggested that oral health promotion by a visiting trained dental nurse or dental therapist to educate and increase awareness amongst carers of the elderly showed some evidence of success, however, further eligible studies would be required.⁷¹

Where a patient has a key worker/dominant carer, comprehensive education about the aetiology of the disease process should be given in language that is easily understood and any risk factors specific to the patient explained. The aetiology of gingival bleeding should be discussed and care-givers encouraged to brush bleeding points as many may otherwise believe that they are making the situation worse.⁶⁸ The specific daily oral hygiene needs of the patient should be confirmed as a personalized written oral hygiene instruction plan which should be readily accessible to all staff involved in the patient's care (Figure 11).^64,65 This should be accompanied by visual images/pictures of how each OH aid should be used and their frequency of use.⁶⁵

Ideally, times of day should not be specified and should fit around the usual routine of the patient, at a time when they may be most co-operative.⁷⁰ It is perfectly acceptable for a care-giver to perform just one episode of oral hygiene per day if it is effective.⁶⁵ Systems should be in place for goals to be set, monitored and reviewed regularly by an oral health promotion team. Appropriate review times will vary dependent on carer knowledge, the patient's oral hygiene status and periodontal risk but may range from as little as once a week to every 6 months.

Appropriate prevention tools

Amongst a plethora of oral hygiene aids, choosing the most appropriate for an individual is crucial to success. Those with limited dexterity or loss of fine motor skills may realistically struggle with certain oral hygiene tools. The 4th European Workshop of Periodontology 2002 and Cochrane reviews in 2003,⁷² 2005⁷³ and 2014⁷⁴ all confirm that battery powered toothbrushes are significantly more effective in plaque reduction and accompanying gingivitis when compared to a manual toothbrush. These should be strongly encouraged in all patients who can tolerate them. For those with physical limitations, the bigger handle, better grip and ability of the brush to remove plaque with little patient manipulation can be advantageous. Modification of the toothbrush handle may be helpful. Examples include (Figure 12):

In circumstances where an electric toothbrush cannot be used successfully due to a dislike of the vibrations or a patient's restricted mouth opening, the ‘Barman's Superbrush’ may be considered. This brush consists of a three-sided head, able to clean the buccal, occlusal and lingual surfaces of the teeth simultaneously, potentially useful when co-operation for an open mouth may be for a limited time period (Figure 13).

In patients with physical or mental impairments, who require some or total help in brushing their teeth, the Barman's brush has been reported to improve plaque removal on smooth surfaces by up to 25% when compared with a manual toothbrush.^77,78 However, results should be interpreted with caution owing to a small study sample size.

Significantly, both studies confirmed that electric toothbrushes were more effective than the Barman's brush for those patients able to tolerate the vibrations and brush without additional assistance. To ensure the best results with a toothbrush, regular replacement every three months is advisable.⁶⁵

The British Society of Disability and Oral Health in its 2012 Guidelines suggest a number of practical solutions for overcoming specific problems when trying to brush the teeth of those with learning disabilities.⁷⁹ A bedi wedge or finger prop may be useful for very unco-operative patients. It consists of a simple reinforced plastic device, placed inbetween the teeth to reduce the risk of being bitten or seriously injured, whilst ensuring that the patient's mouth stays open for toothbrushing. Gentle, clinical holding may be required with this. Biting of the toothbrush by an individual may almost act as a prop and may be left there whilst the teeth are cleaned with another toothbrush (Figures 14 and 15).

If gagging occurs, a small round or narrow toothbrush head with a double tuft may be used (Figure 16).

Still in its infancy is the development of a 3-D printed toothbrush, using models of the patients' teeth. The toothbrush is placed into the mouth like a mouthguard, with 3D bristles positioned exactly to contact every single point of every single tooth. A patient's grinding or clenching motion would be sufficient to brush the teeth in this way. Although no clinical trials have been carried out, this presents a potentially novel way of improving oral hygiene in this group.

In conjunction with toothbrushing, interdental cleaning helps attain optimal oral health. In cases where oral hygiene is very poor, advice must be staged. Toothbrushing advice should always be given first and only if adequate should advice on interdental care be pursued.⁶⁴

Just like toothbrushing, a myriad of devices exist to access interdental spaces. The manual dexterity required for effective flossing is high and patients often find it challenging⁸⁰ with low levels of compliance.⁸¹ Christou et al demonstrated that interdental brushes were preferable to floss for the removal of interdental plaque in patients suffering from moderate to severe periodontitis and had a higher patient preference.⁸² However, a more recent review suggests insufficient evidence for this conclusion.⁸³ In the case of patients who have very tight contact points or small embrasure spaces, the better grip attained with a floss holder may be advisable, though research shows no difference between the efficacy of this and hand-held floss (Figure 17).⁸⁴

The daily use of oral irrigators has been gaining increasing popularity. Although two reports, one involving a case study and another that compared toothbrushing to a Water Flosser alone, questioned the plaque removal capabilities of water flossing, a subsequent literature review looking at multiple randomized controlled, single-blind studies refutes those results.⁸⁵ These studies have shown significantly greater reductions in plaque, calculus, bleeding, gingivitis and PPD when oral irrigation is used as an adjunct to toothbrushing, compared to floss and toothbrushing.⁸⁶ Additionally, the irrigators demonstrate an ability to modify the host response by subgingival disruption of bacteria, an increase in anti-inflammatory mediators and a decrease in pro-inflammatory cytokines.^87,88 As such, patients with immune defects may further benefit from its use.⁸⁹ Fine motor control with fingers is not important and it represents a potentially good solution for those where dexterity is poor (Figure 18).⁹⁰

Disclosing tablets have been found to be a particularly good capacity building and motivational tool for both patients and care-givers and thus should be encouraged prior to toothbrushing (Figure 19).⁷⁰

The environment where oral hygiene is being implemented is important. A calming, quiet atmosphere with a particular care-giver that the patient is well acquainted with can make a difference. ⁷⁰

Poor nutrition

Those with learning disabilities are much more likely to be underweight or obese when compared to the general population.²² A study of adults with learning disabilities found that 28% of men and 39% of women were obese, with the prevalence being higher in people with a mild to moderate learning disability compared to those with a severe to profound disability.⁹⁶ Excessive weight gain may be an associated part of several genetic syndromes, including Pradi-Willi, Down's, Carpenter, Lawrence Moon and Cohen syndromes.^97,98 Obesity has been reported as a significant risk factor for periodontal disease, indirectly by increasing a patient's risk of diabetes,⁹⁹ but also directly with an increased BMI being positively related to the severity of periodontal attachment loss.⁹¹ Although no clear aetiology has been established, it has been suggested that adipose tissue may serve as a reservoir for inflammatory mediators, thus contributing the necessary pathogens for disease.¹⁰⁰

In addition to obesity being a risk factor for periodontal disease, a lack of fruit and vegetable consumption in combination with increased consumption of fatty foods has been shown independently to increase the risk of periodontitis by 2.3 times, with research demonstrating that adjunctive daily supplementations during a course of non-surgical therapy offers additional pocket depth reductions and improvements in BOP.¹⁰¹

Carers should be encouraged to monitor patients' weight and food intake, thus identifying nutritional problems as soon as they occur. Direction towards the WHO's ‘healthy eating advice’ should be available in all care homes and encouragement in sports participation and other physical activities with friends, family members/other care home residents may provide them with entertainment and a better overall sense of wellbeing. It is important to remember that weight may be a sensitive subject for any individual and should be approached with sensitivity and realistic targets.¹⁰² Correspondence with the patient's general medical practitioner or local community services will allow liaison with local dietitian services.