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

October 2004

Healthy People 2010, Objective 21-10: “…increase the number of adults and children who use the oral health care system each year to 83%.”

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/nohss/index.htm

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

For more information, contact:

Meg Traci, Director  matraci@ruralinstitute.umt.edu
Montana Disability and Health Program
The University of Montana Rural Institute
52 Corbin Hall, Missoula, MT 59812-7056
888-268-2743 toll-free;
406-243-5467 Voice;
406-243-4200 TTY
406-243-2349 (fax)
http://rtc.ruralinstitute.umt.edu

The Montana Disability & Health Program

Opinions expressed are those of the authors, and not necessarily those of the funding agencies.
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