The oral problems of people with disabilities are rarely noticed, but the need for oral medical or nursing care for people with disabilities is great. The increase in human medical care and higher life expectancy rates, along with the increase in life expectancy and the aging of society, will certainly be accompanied by an increase in the acquisition of a chronic or severe disability in life. From national medical institutions and their placement in community homes for the elderly, as well as family retirement, etc., the concerns of this group are bound to receive increasing attention, and their oral problems are increasingly highlighted. The oral health status of people with disabilities reflects the level of social civilization.
According to the United States, about one in five Americans has a disability and one in ten has a severe disability. Functional disabilities, activity and work disabilities, and intellectual disabilities, including some mental illnesses, are indicated by criteria and abilities. We know that there are two broad types of disabilities that develop in adults: First, disabilities that occur at birth or during development: such as mental retardation, cerebral palsy, epilepsy, and autism. Second, acquired disabilities usually result from trauma such as spinal cord and cranial injuries, or chronic diseases including cancer, diabetes, arthritis, acquired immunodeficiency syndrome (AIDS), degenerative neurological disorders, psychiatric disorders, etc. The most common cause of functional limitations between the ages of 15 – 64 is rheumatism, arthritis or spinal, cardiac, pulmonary, or respiratory disease. The current state of life for people with disabilities is more isolated from society, with little social attention, lower utilization of social resources, and diseases that become more severe with increasing age.
People with congenital disabilities are overwhelmingly poor due to their disabilities, often have low levels of education, are more likely to be unemployed or employed, and are more likely to rely on public service programs for support. Because of their disability and their access to oral health care is much lower than that of the normal population in the same year, economics may be the main reason for those with congenital disabilities, but for those with acquired disabilities, especially those with disabilities due to illness, the conditions for their access to oral health care are also greatly reduced due to the difficulty of travel, or the impact of the primary disease.
The low rate of access to oral health care for people with disabilities is invariably a deprivation of their socioeconomic rights, which is compounded by their disadvantaged status, making it more difficult to solve the problem. In general, few medical institutions focus on oral health care for people with disabilities, perhaps because they are not life-threatening, the procedures are more complex, and it takes more time and communication for physicians to see these patients than for ordinary patients, so they are not popular. Our institution has studied children’s oral problems, as well as geriatric oral problems, but very little has been done on the oral problems of people with disabilities. But this population is increasing, and as the country and individuals improve financially, people are demanding a higher quality of life, and the demand has increased.
Everyone knows that treating this population involves risk taking and it requires a higher level of basic medical knowledge on the part of the practitioner. We know that some of this population is due to oral problems, but many of them are due to other diseases or some oral problems complicated by diseases, and some of them are due to treatment of certain diseases such as medication. This requires the physician to also have an understanding of the causes of disability in such patients and ways to control the primary disease. Many of these problems are not due to mobility or cooperation difficulties, although these problems can cause a lot of trouble in treatment, but more of the problem is the balance between oral treatment and control of the primary disease, and sometimes even with other specialists to discuss their respective treatment plans, so as to reduce the risk.
Dental treatment of special populations is a special field of dental practice, which requires experience for an oral surgeon to focus on their physical and psychological problems in addition to treating their oral problems. This is because you are dealing with a population with different disease types that are extremely different from what they are facing, the same being the presence of disabilities of varying degrees, especially motor disabilities, and the psychological perception of being marginalized because they may be in such a position at home. When dealing with this group we need to properly assess the patient’s condition and provide them with the best possible services, even if they are not immediately available, we should clearly indicate how to solve these problems and what conditions need to be created to do so. We cannot allow these people to live in pain with a low quality of life and create the conditions to solve them. I personally believe that patience and compassion are more important than technology.
We should give appropriate treatment to patients who are not in the acute phase, and these patients should be accompanied by their families in the planning and treatment. Sometimes it is difficult to determine whether a patient has a mild mental problem, but an experienced practitioner can still understand or catch signs of a patient’s speech and movement.
Treatment of people with disabilities requires special treatment because they may need additional support and cooperation. It is important to first tell the person being treated about the benefits of the treatment, and then tell them about the treatment, the process, precautions, time, and what they need to cooperate with in order to obtain their cooperation. The treatment for people with disabilities is easy to be simple and effective, focusing on the principle of results and not having to seek the whole thing to reduce subsequent complications and repeated multiple follow-ups, which is a burden to them and their families and often not accepted. People with disabilities are dependent on others to varying degrees when they go out, many are unable to make regular follow-up appointments, and try not to opt for treatments that may take more time to complete for them.
Providing dental treatment to patients with severe disabilities requires empathy, patience and a high degree of knowledge and skill. The integrated team, person-centered, individualized treatment provides a comprehensive continuum of care, providing specialized care, using the least amount of moderate restrictive methods when necessary to gain the patient’s cooperation. It is important that we first need to understand the patient’s primary concerns that need to be addressed after the patient with a disability is seen, and our first priority is to address those concerns.
It is recommended that patients with disabilities use treatment visits by appointment, accompanied by a family member who lives with the patient on a permanent basis. This provides the physician with more information about the underlying medical treatment and living situation, which makes it easier for the physician to schedule a time to focus on the patient. Patients with only physical disabilities and no cardiac or cerebral problems often have no problem cooperating with treatment, it is just a matter of how well they cooperate in the hospital to reduce the number of trips the patient has to make. For patients other than these, it is very important to know the past history, which is related to patient safety. A complete history is essential at the patient’s first visit, and the patient’s medical condition needs to be clarified as much as possible during contact with the patient. Specific questions about the disability? specific questions should provide valuable information and an assessment of the patient’s level of functioning to determine the patient’s support system. From knowing who the patient’s legal guardians are and obtaining their consent. It is the dentist’s responsibility to determine who is legally eligible in order to give consent for treatment.
The following addresses the management of treatment for patients with disabilities.
Minimize the waiting and treatment time for the patient.
Adjusting the patient’s chair position requires communication with the patient, and unlike general patient access to the physician, often the physician will have to change position to accommodate the patient. Patients with congestive heart failure or asthma, high spinal cord injuries, cerebral palsy and dysphagia require more vertical positioning. Great care must be taken when moving patients with rheumatoid arthritis or Down’s syndrome, paralyzed by the risk of subluxation of the C1-C2 vertebrae. Wheelchair users must transfer the dental chair in a safe manner, or in some cases consider handling in a wheelchair.
Dental treatment of the routinely disabled varies widely, depending on the degree of disability, the patient’s intellectual disability, the degree of neuromuscular deficit, cognitive status, and the practitioner’s experience in treating the patient. Care should be taken not to overestimate and underestimate the patient’s intellectual disability, and to make every effort to communicate with the patient and gain a grasp of the patient’s condition. Appropriate behavior management methods must define the manner and? range can ensure a calm, friendly atmosphere, and behavioral control can also use medication for sedation or physical restraint if necessary.
Much of the treatment is required to temporarily alter the patient’s original treatment regimen for bacterial endocarditis, including patients with moderate and high risk cardiovascular disease, certain patients on renal dialysis, and people at systemic risk for invasive therapeutic procedures prior to which prophylactic antibiotics may be required. Medications used to treat cardiovascular disease, chronic respiratory disease, psychiatric and other conditions may conflict with medications used in dental treatment, such as anesthetics, sedatives and vasoconstrictors, and must be avoided or used with caution.
Post-operative care is crucial for this population. Treatment in the oral cavity is usually very brief, especially in disabled patients with chronic underlying conditions, and the adjustment of their subsequent treatment to the traumatic nature of dentistry has implications, often with other disciplines having to work together to develop a plan.
Post-operative care for the disabled population is the same as for general patients, and should be repeatedly emphasized both before and after surgery, and if necessary should be communicated in writing. Communication is the key, and post-operative care should be emphasized according to the patient’s acceptance and mental capacity and attitude. Most of the surgical care is done at home or by family members. Patients should be aware of the possible complications and what to look for in the hospital, this is a special group, we should try to prevent complications to a minimum to reduce the chances of patients going to and from the hospital. We should educate our patients on how to do this, and let patients and their families understand the reasoning behind the cooperation between doctors and patients to minimize complications.
Prevention of oral diseases and oral infections is the key to oral health for people with disabilities in their daily lives. Oral health maintenance plans should be developed for different people on an individual basis. We know that the disability of each person with disabilities is different, so it is necessary to make individualized plans. Only for brushing and rinsing, according to different types of disabilities, we can make a plan whether to use toothbrush or rinse mainly; whether to use hard or soft bristle toothbrush for the same brushing; some patients can use rinsing, but some patients are not applicable, etc. The development of the existing technology level of electric toothbrush and flosser has already provided a better solution for The current level of technology development of electric toothbrushes and flushers has provided more opportunities and conditions for oral care for people with disabilities, and we should educate our patients on how to choose the most suitable form for them.
The use of chemoprophylaxis for dental disease in people with disabilities carries a high risk. Various chemotherapeutic agents, including fluoride, chlorhexidine, and fossa sealants have been shown to be clinically effective and affordable. Fluoride is the cornerstone of preventive caries treatment. Regular use of topical fluoride is proven effective in preventing caries, such as the development of oral dryness or dryness syndrome due to the administration of psychotropic or other medications, or radiation therapy to the head and neck, which predispose to caries (mastocytosis). But it is possible to use different ways to achieve caries prevention depending on the type of disability, for example, the use of gel formulations or brushing with fluoride toothpaste may be more suitable for care-dependent types of patients; the preferred treatment for gingivitis is the use of chlorhexidine, the human being is unable to remove all plaque and should be removed mechanically. Different studies have proven that chlorhexidine is popular with people with disabilities. For people who are unable to use chlorhexidine mouthwash, family members can use a flosser to effectively rinse the plaque sprayed on the teeth or gel sprayed on the tooth surface.
For the treatment of special patients
An increasing number of people in our society now have serious physical and psychological problems, and these patients may display resistance and adaptations to maladaptive behaviors and habits and behavioral management techniques that require more than our current clinical capabilities. Many physicians are reluctant to treat these patients, such as poorly controlled seizures, inability to control Parkinson’s disease movements, severe gag reflex disorders, post-tracheotomy, post-gastrostomy, etc. Patients with such complex needs require special care and the services of a team of specially trained and experienced personnel.
The dental management of patients with disabilities, whether severe or not, requires an interdisciplinary approach. Not only does the patient’s special care accompany the efforts of a team of dentists, dental hygienists, and dental assistants, but the dental team must work closely with other health care providers, family members, and social service agencies to facilitate treatment and family coordination Dental and other health care professionals and caregivers must understand the patient’s special needs, motivations, and have the skills to provide the necessary oral health care.
Interrelationship of Oral and Systemic Health
Oral health is a total health, not an isolated single component. People with disabilities are at greater risk for oral disease, and in turn, oral disease further jeopardizes their health. Recent studies have shown an association between oral infections, particularly periodontal disease, and systemic conditions such as heart disease, stroke and diabetes, and even senile dementia, although the causal relationship remains to be established.
Multiple risk factors for oral disease include physical limitations, perceptions of normal oral self-care, communication, behavioral problems leading to lack of knowledge or motivation for oral self-care and lack of caregiver motivation or training to provide oral health services especially to patients with severe oral disease. Dental fears and lack of access to patients with limited transportation can lead to deterioration in their condition.
Disability itself can be a direct cause of oral problems. However, systemic diseases may also have different oral manifestations.
Cerebral palsy, which can be accompanied by severe teeth grinding, can be seen on clinical examination with excessive tooth wear, compromised temporomandibular joints, and abnormal swallowing. Traumatic brain injury also frequently presents with heavy teeth grinding and swallowing defects. These individuals may require the use of pasty foods, resulting in poor oral hygiene.
Dry syndrome in the oral cavity is characterized by significantly reduced salivary flow and dry mouth. The lack of saliva increases the risk of dental caries, periodontal disease, and other oral lesions.
Diabetes increases susceptibility to periodontal disease. Periodontal disease progresses more rapidly in those with risk factors such as dental calculus, and they have more difficulty controlling their blood sugar. Diabetic complications include dry mouth, xerostomia, candidiasis, tongue inflammation, mucositis, surface smoothness, dental caries, and loose teeth are more common.
Infections from progressive periodontal disease may exacerbate the worsening diabetic state. Recent findings suggest that reducing periodontal infections may lead to better glycemic control in diabetes.
Oral lesions in HIV and carriers are often clinical features of first human immunodeficiency virus (HIV) infection and may be used as a predictor of disease progression and/or to monitor the severity of immunosuppression. Predictive lesions include major oral ulcers, necrotizing ulcerative periodontitis, oral Kaposi’s sarcoma, long-standing herpes simplex virus infection, oral hairy white spots, Candida, etc. Although oral manifestations with the use of antiretroviral drugs may control symptoms, studies of HIV-positive, substance abuse, lack of dental care with gum lesions, show a high prevalence of oropharyngeal lesions.
Treatment of disability may increase the risk factors for oral disease and exacerbate the disease process. Reduced salivary secretion due to substance use is a factor in many oral diseases in people with disabilities. Over 400 medications were identified as causing dry mouth. Antipsychotics, tricyclic antidepressants have significant anticholinergic effects and they may cause chronic dry mouth, dental caries, gingivitis, Candida, and other oral mucosal lesions. Gingival hyperplasia is a side effect of medications that, although it is not unique, may lead to severe hyperplasia of gum tissue. This condition includes phenytoin sodium hyperplasia due to epilepsy control with phenytoin sodium. It is also associated with the use of calcium channel blockers, the control of hypertension (nifedipine, diltiazem, verapamil, and others), and the immuno? immunosuppressant cyclosporine A in the prevention of renal and hepatic organ rejection, and other treatments for transplantation and severe rheumatoid arthritis.
Anti-arthritis drugs such as methotrexate may cause severe mouth ulcers, gingivitis, tongue inflammation, and xerostomia.
Patients undergoing cancer treatment often encounter severe oral complications. Surgery for oral and other head and neck tumors may result in permanent loss of physiological structures and severe functional impairment. Oral complications are present in approximately 50% or more of patients receiving systemic chemotherapy and in 100% of patients treated with radiation. Direct toxic complications include mucositis, dry mouth, loss of taste function, nerve and soft tissue necrosis, osteonecrosis, and dental closure. Indirect toxic effects are most notably oral infections and bleeding. Once a patient receives radiation therapy to the jaw, it is extremely dangerous to extract the teeth or perform any aggressive or surgical dental treatment. These patients must receive comprehensive permanent dental care to eliminate infection and reduce sources of trauma and irritation.
People with disabilities often have multiple health problems that affect their oral health and dental care.
Developmental disabilities are rarely isolated disorders, and in a random sample of 333 adults with intellectual disabilities, almost two-thirds of people with disabilities have chronic conditions that require medical intervention. The most prevalent problems were neurological, ophthalmologic, dermatologic, psycho-emotional, muscular or orthopedic conditions.
Twenty percent of people with disabilities require auxiliary accompaniment to complete tests and treatments. People with Down syndrome have a higher incidence of congenital heart malformations, including mitral valve prolapse and endocardial insufficiency, which is a condition of concern in dental practice. Mitral valve prolapse is reported in 50% of individuals with Down syndrome and has an incidence of 5-15% in the total population. Poor oral hygiene and periodontal and periapical infections increase the risk of bacterial endocarditis.
Importance of oral health
Oral health is inseparable from overall health. The oral cavity of a person with a disability has been called his lifeline, and for a person with a high spinal cord injury, the oral cavity is the only part of the body that the individual retains voluntary control over, and the jaws and teeth may serve as the only ones that can control movement. People who have lost their natural dentition and have severe physical or mental impairments may not be able to use dentures to aid in eating, drinking, and verbal communication.
Look at oral health in terms of social values. People with missing incisors do not have a nice smile. People with disabilities are perhaps even more concerned about this than the general population. Facial appearance is an important key to being accepted by others for society. It is just as important for people with disabilities to improve their dental health, enhance their oral care, and have a smile-filled attitude as it is for their quality of life.
The functional status of the teeth and the severity of dental disease correlate with the level of medical conditions and overall health. There is a direct link between the state of dental health and quality of life. Available data suggest that the presence of dental disease generally has a greater impact on health and function than in people without disabilities. In surveys of emergency dental patients, there is a significantly higher proportion of patients with disabilities compared to those without disabilities. Few studies and surveys have been conducted on the oral health of people with disabilities, but the poor oral health status of people with disabilities is undeniable, and therefore the high treatment needs are inescapable.
It is particularly important to conduct oral prevention for people with disabilities as opposed to the general population, based on the epidemiological findings and identification of risk factors related to oral diseases in people with disabilities and training with those who provide care to them, both professional and non-professional (chaperones or guardians), so that each participant gradually has the skills to remove or reduce oral risk factors. These efforts can only be supported through a concerted interdisciplinary effort aimed at improving the oral health status of persons with disabilities, promoting oral health in special needs populations, improving professional and non-professional training and research, and ensuring the necessary government financial investment.