Oral health of adults with intellectual disabilities: a systematic review

Dental decision-making under general anesthesia for patients with disabilities: A qualitative study

AIMS

This paper explores the variables which influence decision-making processes in dentists providing dental care for people with disabilities under general anesthesia (GA).

METHODS

Face-to-face semi-structured interviews were undertaken on a purposive sample. Audio recordings were transcribed and checked for accuracy. Using thematic content analysis methods open codes were developed inductively. Codes were analyzed further by three authors adopting a deductive approach, leading to final coding, sorting and themes, subtheme and framework development.

RESULTS

Three themes emerged. The first theme explored Shared Decision Making, or lack thereof, as it influenced clinical reasoning. The second (Systematic, Analytical) and third (Intuition, and heuristics) themes explored features of clinical judgment as considered under dual process theory. Dentists primarily used intuitive decision-making processes and heuristic styled processes (or cognitive mental frames) assisted in intuition to extract teeth, without engaging type 2 processes.

CONCLUSION

The dentists experience subtle modifiers to their decision-making that ultimately promote extraction of teeth under GA for people with disabilities. Bias training, simulation and post-hoc reflection are examples of recommendations which may be used to improve decision-making in this area.

Caries Experience of Adults with Intellectual Disability in the Western Part of Germany

Background: In Germany, there is limited evidence on the oral health of adults with intellectual disabilities (AwID). Methods: In 2017/18, dental examinations of AwID and a questionnaire survey of their legal guardians were carried out. The mean D3MFT values were calculated to describe the caries experience. The prevalence of AwID with at least one fissure sealant (FS) was determined and associations between caries experience and various sociodemographic factors (e.g., age, gender, living arrangements) were investigated. Results: The data of 132 AwID (mean age 35.2 years; range 18–69 years) could be included. For all AwIDs the mean D3MFT value was 9.5 (95% CI 8.1–11.0). The mean D3MFT value for the 35–44-year-olds was 10.9 (95% CI 8.4–13.4). All caries-free persons (n = 14) were younger than 45 years. Furthermore, the mean D3MFT value for AwID living with their parents was lower at a statistically significant level than that of AwID in independent living arrangements. Moreover, younger AwIDs (18–34-year-olds) with at least one FS had a statistically significantly lower mean D3MFT value compared to those without any FS (D3MFT: 3.0 vs. 6.7). Conclusions: The dental health of AwID has improved in Germany in recent years, but, on average, AwIDs still have more missing teeth than their peers in the general population. Oral epidemiological studies on AwID should include information on their living arrangements to assess potential associations between sociodemographic factors and oral health.

Effectiveness of silver diamine fluoride and glass ionomer cement combined with fluoride varnish in arresting dental caries among intellectually disabled individuals: A randomized controlled trial

AIM

To assess the clinical effectiveness of 38% silver diamine fluoride (SDF) in arresting dental caries when compared to combination of fluoride-containing glass ionomer cement (GIC) and fluoride varnish(FV) (5%) among intellectually disabled (ID) individuals.

METHODOLOGY

A randomized controlled trial was conducted among ID (n = 82) individuals, in permanent posterior teeth with Nyvad score 2 and 3 (active caries) of dental caries, randomly allocated to experimental arm (38% SDF) (n = 41) and control arm (GIC along with FV) (n = 41). The caries arrest rate and caries preventive fraction was observed at 6-months among both groups.

RESULTS

The caries arrest rate was 94.5% with SDF and 90.1% with GIC and FV (p = 0.405).The caries preventive fraction of SDF over GIC with FV was 45%, with hazard ratio (-0.588) at 6 months (p = 0.292). The binary logistic regression revealed that the Odds of arresting caries in SDF group is two times when compared to GIC group with p value = 0.218 which is not significant.

CONCLUSION

The present study concluded that the SDF is as clinically effective as combination of GIC and fluoride varnish in arresting caries. Further research and longer follow-up required for more conclusive results.

Association between motor proficiency and oral health in people with intellectual disabilities

BACKGROUND

People with intellectual disabilities (IDs) may be at increased risk of developing periodontal diseases and dental caries due to poor oral hygiene. Our aim was to investigate motor proficiency factors associated with presence of visible plaque and gingival bleeding in people with IDs. We were particularly interested in the level of dependence, manual coordination and fine manual control of people with ID, as well as the level of exhaustion of the primary caregiver.

METHODS

In this cross-sectional study, 299 people with ID were evaluated for oral hygiene using the simplified Visible Plaque Index and for gum inflammation using the Gingival Bleeding Index. The Bruininks-Oseretsky Motor Proficiency Test assessed motor proficiency through fine manual control (fine motor integration and fine motor precision) and manual coordination (manual dexterity and upper limb coordination). The level of dependence was assessed by the Katz dependency index, and the caregiver was tested for exhaustion using the fatigue severity scale. Prevalence ratios [and 95% confidence intervals (CI)] were calculated using crude and adjusted Poisson regression with robust variance.

RESULTS

The exhaustion of the caregiver was associated positively to visible plaque [prevalence ratio (PR) = 1.36; 95% CI 1.06-1.65]. For gingival bleeding, people with IDs that had better fine motor integration (PR = 0.49; 95% CI 0.33-0.75) and precision (PR = 0.50; 95% CI 0.26-0.94), as well as manual dexterity (PR = 0.62, 95% CI 0.49-0.77), presented better results.

CONCLUSION

Poor oral hygiene and gum inflammation were associated with motor proficiency of people with IDs and caregivers' exhaustion. Interventions to improve the oral health of people with IDs should take into account such conditions.

The Oral Status Survey Tool: construction, validity, reliability and feasibility among people with mild and moderate intellectual disabilities

BACKGROUND

A lack of robust data about the oral health of people with intellectual disabilities (IDs) contributes to health disparities. Appropriate research tools are therefore needed. This study reports the construction and evaluation of the Oral Status Survey Tool (OSST), designed to be administered with people with disabilities by non-dental personnel.

METHOD

Oral Status Survey Tool construction and evaluation was achieved adopting a non-clinical construction and content validation phase and a clinical phase to test concurrent validity, reliability and feasibility. Final refinements were also made.

RESULTS

The OSST conceptual framework covered oral function (tooth count, denture wear and opposing pairs of teeth) and oral disease/treatment need (soft tissue status, oral cleanliness, gum condition, carious teeth and oral pain). A systematic literature review identified no existing suitable indices. Candidate items were identified and validated by experts generating content validation ratios. This framework was modified later to expand the function construct. In the initial clinical phase, 49 out of 60 participants underwent examination with OSST and standard dental assessments. All had mild to moderate IDs. Mean age was 43 years (SD = 16), and mean number of teeth was 22.1 (SD = 8.6). Data collectors included two dentists and three non-dentists. Later, a further 17 adults (nine female and eight male) with mild/moderate IDs were included for refinement. At this stage, data collectors included two dentists and five non-dentists. Concurrent validity was established for tooth count [intraclass correlation coefficient = 0.99 (95% confidence interval, CI: 0.99-0.99)], carious teeth [Gwet's AC2 = 0.94 (95% CI: 0.89-0.99)] and gum condition [Gwet's AC1 = 0.84 (95% CI: 0.64-1)]. For all final OSST items, inter-rater reliability ranged from moderate to very good; median test-retest reliability ranged from moderate to good. Acceptability was demonstrated for data collectors and participants. Mean time to complete the OSST was 7 min.

CONCLUSIONS

The OSST is a novel tool that can record a range of clinical oral features including tooth count, denture wear, occluding pairs of teeth and functional dentition, oral cleanliness, gum condition, carious cavitation and oral pain that will be useful within health surveys of people with mild-moderate IDs and similarly neglected populations. The tool demonstrates promising attributes and acceptability. From this study, the OSST appears to be a robust tool that can be incorporated into general data collection for people with mild-moderate IDs and similar populations. A key feature is that it can be administered by well-trained non-dentists.

Failure on all fronts: Qualitative analysis of the oral health care experience in individuals with intellectual disability

AIM

To explore the oral health care experience of individuals with intellectual disability and their families.

METHODS

A qualitative approach utilising face-to-face semi-structured interviews with parents of individuals with intellectual disability. All interviews were audio recorded and transcribed verbatim, and Qualitative Framework Analysis was used to present the results.

RESULTS

Twenty-six parents of 26 individuals with intellectual disability were interviewed. The interviewees were 10 males and 16 females, and their average age was 46.4 ± 11.2 years (range 28-66). The average age of individuals with intellectual disability was 17.9 ± 9.2 years (range 6-48), and there were 11 (42.3%) males and 15 (57.7%) females. The interviewees reported that challenges to oral health care do occur on multiple levels: (a) home environment; (b) primary dental care; (c) secondary dental care facilities; (d) health and education policies and systems; and (e) societal views on individuals with intellectual disability.

CONCLUSION

Individuals with intellectual disability and their families are being failed at multiple levels of oral health care, leaving parents feeling frustrated, isolated, and sometimes helpless. Collaborative efforts are needed to train families to prevent oral health disease at home, establish better primary and secondary oral health care systems, and overcome wider cultural, social, and economic barriers.

Dental attendance, restoration and extractions in adults with intellectual disabilities compared with the general population: a record linkage study

BACKGROUND

Oral health may be poorer in adults with intellectual disabilities (IDs) who rely on carer support and medications with increased dental risks.

METHODS

Record linkage study of dental outcomes, and associations with anticholinergic (e.g. antipsychotics) and sugar-containing liquid medication, in adults with IDs compared with age-sex-neighbourhood deprivation-matched general population controls.

RESULTS

A total of 2933/4305 (68.1%) with IDs and 7761/12 915 (60.1%) without IDs attended dental care: odds ratio (OR) = 1.42 [1.32, 1.53]; 1359 (31.6%) with IDs versus 5233 (40.5%) without IDs had restorations: OR = 0.68 [0.63, 0.73]; and 567 (13.2%) with IDs versus 2048 (15.9%) without IDs had dental extractions: OR = 0.80 [0.73, 0.89]. Group differences for attendance were greatest in younger ages, and restoration/extractions differences were greatest in older ages. Adults with IDs were more likely prescribed with anticholinergics (2493 (57.9%) vs. 6235 (48.3%): OR = 1.49 [1.39, 1.59]) and sugar-containing liquids (1641 (38.1%) vs. 2315 (17.9%): OR = 2.89 [2.67, 3.12]).

CONCLUSION

Carers support dental appointments, but dentists may be less likely to restore teeth, possibly extracting multiple teeth at individual appointments instead.

Restoration of an Upper Anterior Tooth in an Adolescent with Autism Spectrum Disorder-A Student Case Report

BACKGROUND

Patients with autism spectrum disorder (ASD) or other mental or physical limitations experience an imbalance in the frequency of dental treatment as compared with the general patient population, in part, due to inadequate pre-graduate training of future dentists.

CASE PRESENTATION

This case report describes a successful anterior tooth restoration, in awake state, in a 15-year-old boy with early childhood autism. The procedure was carried out independently by students of dentistry within the scope of their integrated clinical training semesters. Desensitization sessions were used as a preparatory measure and elements of behavioral facilitation (tell-show-feel-feel-do) were applied during the treatment.

CONCLUSIONS

To avoid discrimination of this group of patients in the provision and quality of dental care, a structured approach to the transfer of theoretical and practical knowledge in the field of special care dentistry is indispensable. To this end, treatment strategies for special care patients should be taught to pre-graduate dental students as a fundamental part of their university curriculum.

What is it about carer-led oral hygiene interventions for people with intellectual disabilities that work and why? A realist review

OBJECTIVES

To undertake a realist review of carer-led oral hygiene interventions for people with intellectual disabilities. This was run parallel with a Cochrane Review.

METHODS

Realist review methods were followed. This was characterized by an iterative process of developing and refining theories of how interventions might work, expressed as context-mechanism-outcome configurations. The steps included identifying candidate theories with local and international expert consultation before applying an iterative search strategy. Selection criteria were applied for screening of the abstracts and 10% of the included full texts were screened by the three review members, independently, to ensure adherence to the criteria. Data were extracted in NVivo and synthesized qualitatively to confirm, refute or refine theories about what works, why, in what circumstances and for whom.

RESULTS

Of the 697 potential sources, 112 studies progressed to full-text screening, and 58 of those were included in the review. These 58 studies found evidence to support six theories about carer-led oral hygiene interventions for people with intellectual disabilities, from a starting point of ten candidate theories. This realist review found evidence to support the contention that, in order for carer-led oral hygiene interventions for people with ID to succeed, there is a need for adequate resources and a system-level approach; involving carers in design and implementation; tailoring of training to suit carers' needs and work environments; clearly stating how interventions are expected to work; specifying goals with achievable steps for carers to follow; providing carers with support and feedback on their efforts; acknowledging the physical and emotional toll caring for people with intellectual disabilities has on the well-being of carers; and repeating training.

CONCLUSIONS

The theories from this realist review will direct future interventions by suggesting the mechanisms and contexts that are important to achieve the intended outcome of improved oral health for people with intellectual disabilities. These are, of course, propositions intended for testing, rather than proven. The parallel use of Cochrane and realist methods provides a unique richness to our hypothesis of what works, for whom, when and how.

Association between disability status and dental attendance in Australia-A population-based study

AIMS

Disability is a key social determinant of health. The objective of this study was to test the association between disability status and irregular dental attendance among the Australian population, and to examine whether the observed association varied among adolescents.

METHODS

Data on 17 501 participants from The Household, Income and Labour Dynamics in Australia (HILDA) were analysed. The main outcome examined was irregular dental attendance (two or more years since last dental visit) with disability as the primary exposure. Multivariable logistic regression models were fitted to test the associations between disability and dental attendance pattern. Models were adjusted for age, gender, country of birth, region of residence, education and income. Analysis was repeated among adolescents (15- to 24-year-old) to examine for variations in observed association.

RESULTS

One in four participants reported having a disability. Unadjusted model showed that the odds for irregular dental attendance were 1.40 times greater (95%; CI, 1.30-1.51) in those with disability than those without disability. After adjusting for all covariates, participants with disability had 1.20 times higher odds (95%; CI 1.10-1.30) of irregular dental attendance than those without disability. Irregular dental attendance was 1.41 times greater (95%; CI 1.10-1.80) in those with disability aged 15-24 years than those without disability.

CONCLUSIONS

Australian individuals with disability are more likely to have irregular dental attendance than those without.

Nonpharmacological techniques to support patients with intellectual developmental disorders to receive dental treatment: A systematic review of behavior change techniques

AIMS

To identify the nonpharmacological patient-support techniques (nPSTs) reported, used or recommended for people with intellectual-developmental-disorders (IDD) to receive dental treatment; to identify their active ingredients and evaluate their effectiveness by adopting an existing taxonomy of behavior-change techniques (BCTs).

METHODS AND RESULTS

Following a protocol, a search strategy was undertaken using Medline, Embase, Cochrane Library, Scopus, Cinahl, and Psychinfo (EBSCO). Selection criteria were applied, with review and extraction in duplicate. A comprehensive list of nPSTs were identified and coded by their constituent behavior-change techniques (BCTs), where BCT-taxonomy-Version-1 criteria were satisfied. Quality assessment was undertaken and effectiveness of BCTs reported. From 915 screened articles, 23 were included. In 207 instances nPSTs were identified, representing 46 distinct nPST techniques, such as positive-reinforcement (n = 18) and tell-show-do (n = 9). Of the 207 nPST codes, 135 were coded as BCTs (65.2%). The most commonly coded BCT was demonstration of the behavior (BCT6.1; n = 25). Considering studies of interventions (n = 11), all were at moderate to critical risk of bias. No interventions or outcome measures were comparable across studies.

CONCLUSION

This is the first review to bring together techniques dentists use in practice and theory-driven BCTs. A significant overlap between nPSTs and BCTs was evident supporting the use of BCT taxonomy to code dental interventions. No strong evidence supporting any intervention was identified.