Research Progress Report #29   Research Progress Report #30

Have Healthy Teeth

 

Rural Disability and Rehabilitation

Research Progress Report #29

 

Oral Health and Hygiene: Priorities for Adults with Intellectual and Developmental Disabilities

October 2004

People with intellectual and related developmental disabilities (I/DD) historically received oral health services in institutional settings. Today, most people with I/DD live in community group homes or transitional living arrangements, and use community oral health services. Background: In 1999, RTC: Rural researchers used the Life Quality and Health for Adults with Developmental Disabilities: A Secondary Conditions, Risk and Protective Factors Surveillance Instrument to gather information from direct service staff on the prevalence and severity of secondary conditions among the 1,925 adults with I/DD served by the Developmental Disabilities Program of the Montana Department of Public Health and Human Services (DPHHS). 749 surveys (39%) were returned. The survey asked about each individual's health, including oral health and hygiene: 1. Number of visits for dental care and/or teeth cleaning. 2. Presence of own teeth, dentures, or no teeth/appliance. 3. Frequency of, and difficulty with, tooth brushing. 4. Amount of limitation associated with a dental/oral hygiene secondary condition (Figure 1). 5. Existence of an Individual (Habilitation) Plan objective addressing this secondary condition. Figure 1. Secondary Condition Survey: Dental/Oral Health Item Description of Figure 1.

0 1 2 3 IP? Yes No

Dental/Oral Hygiene Problems

People with developmental disabilities are at greater risk for dental malformations and disease. Teeth may be missing, thinly enameled, abnormally shaped, or poorly cared for. This can lead to decay, a poorly fitting bite, tooth aches, or progressive tooth loss. You may also observe consistent bad breath, which can indicate tooth decay or infection. Poor dental hygiene can limit social interactions or eating pleasure.

Survey Results: We compared this sample of Montana adults with I/DD with other adult Montanans surveyed by the 1999 Behavioral Risk Factor Surveillance System (BRFSS). In 1999, more adults with I/DD (79%) visited a dentist than did other Montana adults (64%). Many of the adults with I/DD (40%) had multiple dental visits (range: 2-12, no comparable BRFSS data). Fewer adults with I/DD (42%) had their teeth cleaned than did other adult Montanans (62%); adults with I/DD may have visited the dentist more often for treatment than prevention. In the sample of adults with I/DD: 1. 82 % had their own teeth (mean age = 40.7 years). 2. 5.5 % had a partial denture (mean age = 53.9 years). 3. 8 % had a full denture (mean age = 58.3 years). 4. 5.4% neither had their own teeth nor a denture (mean age = 57.6 years). Reasons for tooth loss in these adults with I/DD were not cited. Although the percentages are not directly comparable to the 1999 Montana BRFSS descriptions, 19 percent of adult BRFSS respondents had lost six or more teeth to decay or gum disease. While this is similar to the number of adults in the I/DD sample with reported tooth loss (18.8%), fewer adults with I/DD were age 64 or older (8.8%). More than twice as many BRFSS respondents (19.3%) were 65 or older. Tooth loss is consistently associated with increased age. Therefore, one would expect more BRFSS respondents to report total tooth loss than the younger survey sample with I/DD. However, more than half (51%) of respondents with I/DD who were 65 or older had a full denture or had no teeth/no denture, while only 29.2 percent of 1999 Montana BRFSS respondents aged 65 or older had no permanent teeth. Tooth brushing frequency varied among the respondents with teeth (no comparable BRFSS data): 1. 6% reported brushing less than once a day 2. 24.2 % brushed once a day 3. 66.6 % brushed more than once a day 4. About half of the sample (48.3%) brushed their teeth independently 5. Of those requiring assistance, 8 percent required complete assistance. In this sample, dental/oral hygiene problems were common and severely limiting -- 39 percent reported having dental/oral hygiene problems that limited their activities 5-10 hours per week. Poor dental/oral hygiene ranked as the sixth most-limiting of 45 secondary conditions. Only communication, physical fitness, weight, personal hygiene, and persistence/low frustration problems ranked higher. Almost one-quarter (24.2%) of the sample's individual (habilitation) plans addressed dental/oral hygiene problems. Individuals with more limitation from this secondary condition were more likely to have dental/oral hygiene-related treatment plans. However, only half of the 6 percent of respondents with chronic or significant limitation (>ten hours a week) due to dental/oral hygiene problems had a treatment plan to address it. Our findings that the respondents with epilepsy (17.5 %) reported statistically more-severe dental/oral hygiene problems are consistent with the literature on side effects of seizure-control medications . Emerging literature also cites the importance of direct service staff in supporting routine oral hygiene behaviors. This was consistent with our observation that persons whose habilitation aides had changed during the prior two years reported statistically greater limitation from dental/oral health problems. Conclusions: National surveillance instruments (such as BRFSS) either exclude or fail to identify respondents with I/DD. Therefore, these sample data on the oral health of adult Montanans with I/DD are important for state planning. Our state plan must consider that there is only one dentist per 1,920 Montanans, and our population is spread across a large, predominantly-rural area. Montana must recruit qualified dental professionals, especially those with expertise in treating individuals who have special health care needs. The national prevention agenda must be Montana's cornerstone for an oral health plan that emphasizes programs supporting good oral hygiene habits. Many adults with I/DD require specialized oral health training and treatment (AAPD, 2004), but few dental school graduates are trained to provide it (Wolff et al., 2004). Our state's over-extended dentists sometimes deny care to Medicaid and Medicare beneficiaries (including adults with I/DD). Finally, although the need is great, we have found few empirically-tested preventive programs that support good oral hygiene habits in this population. Next Steps: RTC: Rural researchers have piloted a simple, inexpensive program to support daily oral hygiene behaviors of adults with I/DD. Program participants are taught to brush, and receive brushing devices, daily reciprocal peer support, and reinforcement. Preliminary data on plaque, gingivitis and debris show that oral health improved within six weeks. The Montana Disability and Health Program, a partnership between The University of Montana Rural Institute and Montana DPHHS, plans to implement this program more broadly with interested Montana People First chapters and further evaluate its effectiveness. Resources: Behavioral Risk Factor Surveillance System http://www.cdc.gov/brfss/ National Oral Health Surveillance System http://www.cdc.gov/oralhealthdata/overview/nohss.html Dental Education in Care of People with Disabilities Program, School of Dentistry, The University of Washington http://www.dental.washington.edu/departments/oral-medicine/decod-program.html American Academy of Pediatric Dentistry http://www.aapd.org/ National Oral Health Information Clearinghouse http://www.ninds.nih.gov/find_people/government_agencies/volorg687.htm References: Casey, M., Davidson, G., Moscovice, I., et al. (2004). Access to Dental Care for Rural Low Income and Minority Populations: Working Paper Series. Minneapolis: The University of Minnesota. Wolff, A.J., Waldman, B., Milano, M., et al. (2004). Dental students' experiences with and attitudes toward people with mental retardation. The Journal of the American Dental Association,135, 353-357. U.S. Department of Health and Human Services. (2000). Healthy People 2010: Volume II. Second Edition. With Understanding and Improving Health and Objectives for Improving Health. Washington, DC: US Government Printing Office. U.S. Department of Health and Human Services. (2003). A National Call to Action to Promote Oral Health. Rockville, MD: National Institute of Dental and Craniofacial Research. The information provided in this report was supported by grant #U59/CCU821224 from the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the author and do not necessarily represent the official views of CDC. This report was prepared by Meg Ann Traci, Ph.D., copyright RTC: Rural, 2004. It is available in standard, large print, Braille, and ASCII DOS text formats. Return to top of page  

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Rural Disability and Rehabilitation

Research Progress Report #30

  Oral Health Program for Adults with Intellectual and/or Developmental Disabilities: Results of a Pilot Study

November 2004

In the fall of 1999, RTC: Rural researchers assessed the amount of limitation associated with 45 secondary conditions experienced by adults receiving services from Montana Developmental Disabilities Programs (DDP). Dental and oral hygiene problems were among the ten most common and limiting secondary conditions (Rural Disability and Rehabilitation Research Progress Report #29). This report describes a low-cost behavioral intervention targeting this secondary condition and evaluation results from a pilot study. Background: The Surgeon General's National Blueprint to Improve the Health of Persons with Mental Retardation highlighted disparities in access to services, reimbursement, and in availability of trained practitioners. This focus on health disparities experienced by persons with disabilities is echoed by the National Institute of Dental and Craniofacial Research's National Call to Action to Promote Oral Health. To address the needs of adult Montanans with I/DD, we considered several key issues -- dental professional shortages, economic barriers, and lack of knowledge. First, rural areas have a shortage of dentists and dental hygienists. In 2002, seven of Montana's 56 counties had no dental professionals, eleven had no dentist, and 19 had no dental hygienist. Second, most adults with I/DD rely on Medicaid. In five counties no dental professional accepted Medicaid, and 14 counties had only one Medicaid provider. Federal and state fiscal constraints are driving reallocation of Medicaid and other health and human services funding. Dental services are rarely reimbursed adequately and are frequently targeted for funding cuts. In 2002, only 18 Montana counties had low-income dental clinics. Third, few dental professionals are trained to meet some of the unique challenges of working with this population (Wolff, Waldman, Milano, Perlman, 2004; Casamassimo, Seale, Ruehs, 2004). In 2002, eight pediatric dentists (in five urban communities) served the entire state. Given these issues, RTC: Rural researchers developed and evaluated a behavioral program that used available systems of social support. The pilot study evaluated the effects of consistent brushing and individual support on the oral health of adults with I/DD. The focus was on low-cost, self-management and prevention strategies for establishing oral health behaviors in this population. Participants: We selected twelve adults with I/DD who received supported living services. Each participant could independently brush his/her teeth and understand simple instructions. A dentist examined each potential participant and determined that five individuals were ineligible due to missing teeth or untreated decay. One participant withdrew from the study. Two other individuals were recruited for a total of eight participants. Method: Each participant identified a support person to provide reinforcement. Participant-Support teams were randomly assigned one of three novel brushes (double-headed brush, rotary brush, or sonic brush) to use on one side of the mouth. A regular brush was used as a control on the opposite side. Several screening tools assessed participants' oral health: the Simplified Oral Hygiene Index for Debris and Calculus (OHI-D, OHI-C), the Lobene Stain Index (LSI), and the Gingivitis Index (GI). A dental hygienist, unaware of the specific intervention, used each tool to screen participants prior to teeth cleaning. Screening was repeated at the start of the study (one week after cleaning). The GI also was performed after weeks 1 and 3. At the study's end (week 6) the same hygienist again performed all screens. Participants' health and secondary conditions were surveyed at the beginning and end of the study. Brushing behavior and self-efficacy also were surveyed prior to the study, after week 3 and after week 6. To negate the effect of right- or left-handedness, the side of the mouth used for the novel or regular brush was randomly assigned within each group (double-headed, sonic, and rotary). Participant-Support teams learned to use the toothbrushes correctly, and participants received laminated cards to mount by their mirrors showing on which side each brush should be used, how much toothpaste to apply, and proper brushing technique. Each participant received a tube of toothpaste (brand obscured for neutrality) and was verbally prompted in how much to use. Participants brushed all tooth surfaces in each quadrant of their mouths for 30 seconds each. Each support person provided one daily prompt plus bi-weekly verbal reinforcement, and logged the type of support given and the time involved. Results: There were significant changes on all screening tools from the study's beginning to its completion (LSS, p=.007; OHI debris p=.095; GI, p= .000). Total changes in screening results, (based on high vs. low scores at study initiation), were -1.7 and -.70 respectively. Description of Figure 1: Changes in Oral Status Aggregated across Regular and Assigned Brush Conditions. Each group had only two or three participants, so we cannot statistically assess the effect of brush type on oral health screens. However, all novel brushes seemed more effective than regular brushes at reducing gingivitis and plaque. Participants initially preferred mechanical brushes, but had no clear preference at study's end. Support persons spent an average of 36.2 minutes (range 2.1-167 mins.) each week providing supports such as telephone calls (37.9%), observation (28.7%), and face-to-face prompts (26.8%). Based on state direct service staff wages ($8.40 avg., range $7.11- $9.71), supports would cost approximately $5.04 (range $.29-$23.38) per month. Participants initially were neutral about reinforcement, but were positive at the study's end.   Description of Figure 2: Changes in Oral Health Indices in Novel vs. Manual Brush Conditions

Conclusions:

1. Routine brushing twice daily for 2 minutes in all parts of the mouth reduces plaque, gingivitis, and debris. 2. Participants' brush preferences vary, with no strong preference for mechanical over manual brushes once the novelty is past. 3. Maintaining a routine brushing schedule requires minimal support time and cost. 4. Five of the eight participants responded to a six-month post-intervention call and were brushing at least twice daily without prompts. Public Health Implications: Although good oral health behavior is a goal of individual plans for individuals with I/DD, little is known about effective types of brushes and brushing behavior. These results suggest that, with clear instructions and minimal support, adults with I/DD will improve and maintain good dental hygiene. Many public health settings could use these methods to support ongoing behavior change and possibly reduce the need for more expensive oral care. Next Steps: The Montana Disability and Health Program (MTDH) is a partnership between The University of Montana Rural Institute and the Montana Department of Public Health and Human Services. MTDH plans to work with interested Montana People First chapters to implement this oral health program more broadly and further evaluate its effectiveness. References: American Dental Association. (2000). Gum Disease. Available: http://www.ada.org/ Casamassimo, P., Seale, N., & Ruehs, K. (2004). General dentists' perceptions of educational and treatment issues affecting access to care for children with special health care needs. Journal of Dental Education, 68, 23-28. Cumella, S., Ransord, N., Lyons, J., et al. (2000). Needs for oral care among people with intellectual disability not in contact with community dental services. Journal of Intellectual Disability Research, 44, 45-52. Feldman, C., Giniger, M., Sanders, M., et al. (1997). Special Smiles: Assessing the feasibility of epidemiologic data collection. Journal of the American Dental Association, 128, 1687-1696. Gabre, P. & Gahnber, L. (1997). Inter-relationships among degree of mental retardation, living arrangements, and dental health in adults with mental retardation. Special Care Dentistry, 17, 7-12. Traci, M. (2004). Oral Health and Hygiene: Priorities for Adults with Intellectual and Developmental Disabilities. Rural Disability and Rehabilitation Research Progress Report #29. Missoula: The University of Montana Rural Institute. Traci, M., Seekins, T., Szalda-Petree, A. & Ravesloot, C. (2002). Assessing secondary conditions among adults with developmental disabilities: A preliminary study. Mental Retardation, 40,2. 119-131. U.S. Department of Health and Human Services. (2000). Healthy People 2010: Volume II. Second Edition. With Understanding and Improving Health and Objectives for Improving Health. Washington, DC: US Government Printing Office. U.S. Department of Health and Human Services. (2002). Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation: Report of the Surgeon General's Conference on Health Disparities and Mental Retardation. Rockville, MD: National Institutes of Health. U.S. Department of Health and Human Services. (2003). A National Call to Action to Promote Oral Health. Rockville, MD: National Institute of Dental and Craniofacial Research. Wolff, A.J., Waldman, B., Milano, M., et al. (2004). Dental students' experiences with and attitudes toward people with mental retardation. The Journal of the American Dental Association,135, 353-357. This report was prepared by Donna Bainbridge, Meg Ann Traci, Tom Seekins, Sherry Peterson, Ryan Huckebe, and Sarah Millar, copyright RTC: Rural, 2004. It is available in large print, Braille and text formats. The Rural Disability and Rehabilitation Research Progress Report series is edited by Diana Spas. The information provided in this report was supported by grant #RO4/CCR818822-03 from the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. Return to top of page