Good oral health is “an important factor in people’s general health and quality of life”.1 However, the evidence shows that people with learning disabilities “have poorer oral health and more problems in accessing dental services than people in the general population”, says Public Health England (PHE) guidance.1
People with learning disabilities may also “need additional help with their oral care and support to get good dental treatment because of cognitive, physical and behavioural factors”.1
Good oral health “involves the practice of cleaning teeth and gums to maintain a clean, healthy mouth, which is free from dental disease, free from pain and prevents decay”, says Dr Balqees Bi, clinical director and specialist in Special Care Dentistry and vice chair of the British Dental Association’s (BDA) England Community Dental Services Committee.
“This, in turn, will help to avoid the need for dental treatments such as fillings and tooth removal. People who have good oral health often have better general health, too.”
Dr Bi says common oral health issues are decay (cavities), gum disease (inflamed, swollen gums, often presenting as bleeding gums), pain or soreness in teeth and gums, infections, and bad breath.
Support for good oral and dental care is “an essential part of promoting good health and quality of life for people with learning disabilities”, says PHE guidance.1
However, research shows that people with learning disabilities have higher levels of gum (periodontal) disease, greater gingival inflammation, higher numbers of missing teeth, increased rates of toothlessness (edentulism), higher plaque levels, greater unmet oral health needs, poorer access to dental services and less preventative dentistry.1
Often people with learning disabilities are dependent on other people to help them with tooth brushing, says Dr Bi. “They may be unable to brush and/or refuse brushing because of challenging behaviour. This may be due to an inability to understand the reasons for brushing or express discomfort or pain before it becomes acute.”
She says that people with a learning disability may also be unaware of dental problems, and due to communication difficulties, these problems are often identified at a later stage.
In addition, they can be at increased risk of some of the general factors that lead to poor oral health and face additional risk factors, including frequent sugar intake, prescription of medications that can reduce saliva flow or increase gingival inflammation, and difficulty in accessing dental services.1
“There are physical, psychological and social consequences of poor oral health, and it can have a major impact on people’s quality of life,” PHE guidance says.1
Poor oral health “can lead to pain and discomfort, which may be hard to communicate for some people with learning disabilities”. Poor oral health is also “significantly associated with major chronic diseases such as cardiovascular disease, diabetes, respiratory disease and stroke”.1
It can “impact negatively on self-esteem, enjoyment of food, communication and ability to socialise” and some people with learning disabilities aware of their dental problems “have reported not wanting to smile”.1
The impact of poor oral health on people with learning disabilities is “pain, misery, and a lack of confidence”, says Adrian Anim, a community practitioner and registered learning disability nurse for the Newcastle West Community Treatment Team, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust. Mr Anim has developed a special interest in oral health, having seen the detrimental impact of poor oral health on people with learning disabilities during his nurse training.
He says there may be challenging behaviour when people are unable to communicate their pain. He recalls how some years ago, a patient with challenging behaviour was admitted to a mental health unit for some months until eventually it was discovered they had abscesses in their mouth and that their behaviour was because of their untreated pain.
According to PHE guidance, there are “multiple barriers to both good oral care and accessing dental services for people with learning disabilities”.1 These barriers include not having a regular dentist and “complex referral systems and long delays in specialist services for people with more complex needs”.1 There may also be “cognitive, physical and behavioural difficulties that impact on someone’s ability to undertake daily oral care and cope with dental visits”.1
Mr Anim says that fear of visiting the dentist or a lack of understanding about the importance of dental care are issues preventing good oral health. He also says that there may be sensory issues for people with learning disabilities, such as difficulties in the waiting room environment.
He adds that a lack of training and awareness among healthcare professionals about oral care are also barriers to good oral health in people with learning disabilities.
Failure to make reasonable adjustments can be another barrier, says Dr Bi. For instance, people with learning disabilities may need longer appointment times, or due to medical complexities, they may have to cancel appointments at short notice.
Dr Bi says that people with learning disabilities may not always be able to engage in prevention (brushing and diet advice) or understand the benefits of maintaining or improving their oral health.
They may also rely on a third party (carers or family) to help them brush and for their dietary needs. “However, carers and families themselves may not be able to provide support if they don’t have the knowledge and the skills to help,” she says.
“We believe it is essential that governments fund programmes to provide training for carers and families in oral health care so they can support those with learning disabilities,” she says. “However, there isn’t a national programme, and while local schemes exist, provision is patchy.”
A holistic assessment, including checking the mouth, will help healthcare professionals to recognise issues with oral health, advises Mr Anim. Not eating or challenging behaviour could also be signs of oral health problems, he says.
He adds that reasonable adjustments are needed to ensure that some people, such as those with learning disabilities, can experience equal treatment. Adjustments are mandated by law to ensure that people with disabilities have equitable access to health care services. Services have a responsibility to make adjustments in accordance with the Equality Act 2010.
In addition, to help reduce anxiety about a visit to the dentist, those supporting the patient could contact the dentist to discuss any issues, says Mr Anim. For example, if an individual struggles with sitting in a waiting room, an appointment request could be made so that they see the dentist straight away.
To help manage oral health in people with learning disabilities, accessible, easy to read information and videos should be made available on how, for example, to brush your teeth and when, and the importance of flossing for healthy gums, says Mr Anim.
Patients with dysphagia or at risk of choking are advised to use non-foaming toothpastes, he says.
“Try to find the toothpaste the person likes or responds to well; for instance, some people with a learning disability or autism can be particularly sensitive to or dislike certain flavours or textures of toothpaste,” says Dr Bi. She says OraNurse is unflavoured and non-foaming and can be a good option if the person is unable to tolerate regular toothpaste. Ideally, people need to brush twice daily with 1450ppmf fluoride toothpaste if they are adults.
“Encourage the person to be involved in their own brushing, if possible – give them something to hold or reward them with something they like to do until they are in the habit. Singing or listening to music can be a good distraction,” says Dr Bi.
If brushing is only tolerated for 30 seconds at a time, a sextant smile chart can be used (see additional resources box) to indicate when and where to attempt the next brush. This is laminated, and a wipe board mark can be used and hung in the person’s toothbrushing area so everyone helping them is aware of what was previously completed, ensuring that all areas of the mouth are brushed, says Dr Bi.
A strong focus on prevention (dietary control and brushing) is crucial, she says.
Some people with certain learning disabilities may have issues moving their arms or hands, and dexterity can be a problem, which makes effective cleaning difficult, says Karen Coates, oral health educator and registered dental nurse at the Oral Health Foundation.
“It is important to reach all the areas of the mouth to clean effectively. A toothbrush with a small to medium head size with soft to medium bristles is usually recommended. There are special handgrips and other adaptations which can be fitted to manual toothbrushes to make them easier to hold,” she says.
In some cases, electric or ‘power’ toothbrushes are recommended for people with mobility problems, she says. However, people with sensory issues “may find the noise and vibration of an electric toothbrush over-stimulating”. “The dentist or dental team will be able to offer advice and practical help on brushing and general mouth care to either their patients or caregivers,” says Ms Coates.
The dental team “wants to support the patient and their parent or carer—and want to listen to what they have to say and where they feel they need help,” says Dr Bi. They will be able to provide patient-centred and holistic support tailored to the needs of the individual.” For instance, carers can ask the dentist for a personalised written oral healthcare plan.
She says factors to consider may include identifying the best time of day to attend a dental appointment, for instance, to fit in with medication or home routines. Who would be the best person to support them at the appointment? What does the dental team need to be aware of? What would help the person feel more confident? And how is it best to communicate with the person?
Box 1
The British Dental Association (BDA) has collaborated with NHS England and leading disability charities and advocacy groups to produce a suite of resources that support the goal of a positive dental experience for all.
A dedicated website – NHS Team Smile – features a series of short videos demonstrating what it’s like to visit the dentist or a member of the dental team, including getting a check-up, a radiograph, having a tooth extracted or a filling, and having your teeth cleaned. The resources are aimed at helping children and adults with learning disabilities to have a positive experience at dental appointments.
There is also a set of SeeAbility versions of the videos with audio descriptions to support people with learning disabilities or autism – who may also have sight loss.
‘Team Smile’ aims to promote a positive dental experience, so that everyone, including adults and children with learning disabilities, who often face extra barriers to care, can maintain good oral health.
Some patients prefer to be seen at certain times of the day depending on their needs, says Ms Coates. “For instance, evening appointments may not be suitable for patients who tire easily or may spend the day worrying. Some patients rely heavily on routine and may need regular appointments at the same time.”
She says it is also helpful if the dental team knows about any concerns or anxieties the patient has so that they can help to make the patient feel at ease.
Visiting the practice before the appointment “can help to reduce anxiety and build familiarity”, she says. “There are books available and information online about dental visits, which may help to show what will happen during a dental visit and help to alleviate fears.”
Some people find it hard to get to the dental surgery, need extra appointment times, or need specific equipment, so the practice may make other arrangements, such as a referral for home visits and special health centres, says Ms Coates.
She says ongoing education and training courses are “vital for all members of the dental team to understand that treating patients with learning difficulties is not something to be avoided or concerned about; they may just need to take the time to explain procedures and take more breaks during the treatment.”
“This would lead to fewer referrals, shorter waiting times and more patients with learning disabilities treated in the dental practice,” she says.
Mr Anim says that healthcare professionals need more education and training on managing the oral health of people with learning disabilities. He says those who support the care of people with learning disabilities can “share best practice through supervision, peer support, and champion groups.”
All health professionals “should recognise that oral health is an integral part of general health”, he says. And it is important for health professionals to be aware of the detrimental impact of poor oral health.
When assessing patients with learning disabilities, he would like health professionals to examine their oral health, including whether they are registered with a dentist, and to promote oral health. “This would improve people’s quality of life,” he says. “In healthcare, it’s time we reconnect the mouth to the rest of the body.”
