Dental News - Interview: Oral health and intellectual disability

Iveta Ramonaite, DTI

Wed. 28. August 2019

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People with intellectual disabilities often have difficulty accessing dental care and maintaining good oral health. As part of the Your Dental Health project, Inclusion Designlab has recently published a guide to educate dental practitioners on issues related to oral health and intellectual disability. Dental Tribune International spoke with Dr Richard Zylan, a member of the Australian Dental Association, and Nathan Despott, manager of Inclusion Designlab, the policy, research and development arm of Inclusion Melbourne, to learn more about the topic.

Dr Zylan and Mr Despott, what are some of the most significant oral health issues that people with intellectual disabilities face nowadays?

Zylan: The main issue is that of undiagnosed and untreated general oral health issues such as periodontal disease and caries, most of which could be easily treated or prevented. From a dental perspective, the dental problems present in patients with disabilities are generally the same as those seen in other patients and usually have the same level of complexity. The treatment plan for a patient with a disability is clinically identical to that provided for any other patient.

Despott: The dentist needs to remember that what divides Australians with intellectual disabilities from the rest of the population is not primarily diagnoses, but rather disadvantage, neglect and poor support, and that these factors often drive poor oral health. It therefore means that, while intellectual disability and poor oral health often go hand in hand, there is no direct causal relationship, and committed, inclusive dentists have the potential to create significant transformative change.

What are some of the greatest barriers to access to dental care for people with intellectual disabilities?

Despott: Added to the social factors are competing priorities. Patients with intellectual disabilities, particularly those living in supported accommodation, often have multiple medical issues, and dental care may not be given the priority it deserves. Caregivers may be overwhelmed by care needs and de-emphasise oral care without realising its importance to overall health. Furthermore, primary care clinicians may forget to ask about oral health if multiple medical problems are competing for attention. This is intensified by the fact that medical and dental professionals rarely have consistent, interconnected communication and planning tools.

Zylan: The difficulties of juggling transport, planning, home care and appropriate staffing levels for appointments at awkward times of the day can result in supported accommodation services postponing dental treatment until a person’s oral health is dire. Financial limitations may also force patients and families to choose between systemic and oral healthcare needs, while modified diets and feeding methods may increase caries risk.

How will this guide benefit dental practitioners and people with intellectual disabilities?

Despott: The Your Dental Health project champions the right of people with intellectual disabilities to receive adequate support to achieve good oral health. It encourages local dentists who work in private and community dental practices to avoid unnecessary hospitalisation for these patients and to build strong, long-term relationships with a cohort who is often marginalised owing to perceived risks and complexity.

Zylan: It also seeks to emphasise an interprofessional approach in which all collaborators understand the role each participant plays in the oral health experience of the individual patient. Everyone involved needs to appreciate the role of person-centred care and to be aware of the impact of culture, behavioural issues and living arrangements on healthcare delivery. They all need to be sensitive to the impact of oral health on overall health for individuals with a disability.

People with intellectual disabilities are significantly more present at general medical practitioner (GP) offices than at dental offices. Additionally, key support workers, family members and accommodation providers are able to frequently monitor or detect oral health warning signs. This means that having an established oral health plan, such as the planning tool in the oral health and intellectual disability guide, can ensure that necessary or urgent treatment is provided on time. This takes on particular importance when dealing with people with intellectual disabilities who regularly experience oral phenomena that may be the base cause of significant general health concerns. This is particularly relevant to people with communication difficulties.

The guide allows both the dental practitioner and the person with an intellectual disability to have a “voice” in cooperative treatment planning and to realise that general anaesthesia should only be used after a range of other approaches have first been explored. For instance, we have recently seen a patient’s parents ask for general anaesthesia to have a tooth extracted since that is how he or she had always been treated in the past, when in reality the patient could have been treated in the chair. This example also raises questions of guardianship.

Despott: Interdisciplinary consultation goes beyond simply engaging with GPs and special needs dentists, though the Your Dental Health project team does indeed support this. It also entails understanding the disability support sector, a sector that is sometimes, often incorrectly, perceived as ambiguous, confusing and unreliable. The Your Dental Health team has found that interdisciplinary consultation, coupled with a modest amount of disability sector knowledge, can lead to significantly smoother treatment, the removal of barriers and wonderful health outcomes for people with intellectual disabilities.

What other measures need to be taken to improve the oral health of people with intellectual disabilities?

Zylan: Increased training and experience in treating patients with an intellectual disability are vital. The actual dental treatment is often not difficult. However, the experience of interacting with people with intellectual disabilities and their families or supporters in a meaningful way requires medium- to long-term commitment. The National Council on Dentistry recently made an announcement regarding the importance of this for dental schools in the US, and this trend will hopefully be taken up around the world.

Despott: There needs to be better inter-sector collaboration, and people with intellectual disabilities, their families, support staff, carers, allied health professionals and GPs all need to be aware of the importance of diet and oral home care, as well as ongoing dental issues.

Zylan: There is also a need for national e-health records that reflect a patient’s combined and interconnected medical and dental history.

Editorial note: Oral Health and Intellectual Disability: A Guide for Dental Practitioners includes a concise overview of evidence-based support practices, access points, and the hierarchical and reporting structures that exist within the disability support sector. One such practice is supported decision-making, a set of principles and techniques that many researchers and policy professionals have begun to codify in practice and legislation in a range of jurisdictions globally. At its core is a long-term approach that involves a circle of supporters assembling to promote the centrality of the voice, will and preferences of the person with an intellectual disability.

The guide is supported by a suite of online and printed resources that dentists and supporters can use in conversation with patients. For example, the Your Dental Health website has three videos describing basic dental treatment and four autism-friendly animations that demonstrate home care techniques.

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