The paper reviews oral health issues and ways to improve them in people with disabilities. Currently, people with disabilities represent 15% of the population (over 1 billion), about 95 million being children between 0 and 14 years (WHO, 2015). For many reasons (limited ability to perform routine personal oral care, oral respiration, sweetened medicines, impaired masticatory function, associated dental abnormalities, etc.), these people, and especially children, are considered to be extremely vulnerable for oral diseases. Compared to the general population, people with disabilities have poor oral health: more teeth extracted, fewer fillings, often periodontal disease. Poor oral health has a negative impact on quality of life, affecting physical, psychological and social well-being. For children, poor dental status can affect their overall growth and health, restrict their participation in the schooling and education process and limit their ability to socialize with confidence and develop normal social relationships. Therefore, prevention remains the simplest and most effective method by which early interception can be achieved, leading to a less complex treatment need, better functionality, better social integration, reduced anxiety and smaller costs.
Key words: disability, oral health, quality of life
Introduction. Definitions and terms
Disability is part of the human condition – almost everyone will be temporarily or permanently impaired at some point in life and those who survive to old age will experience increasing difficulties in functioning (LINK8). Disability is complex and the interventions to overcome the disadvantages associated with disability are multiple and systemic .
According to the World Health Organization (WHO), disability is defined as one or more abnormalities in anatomical structure or the loss of a particular organ or function (either physical or psychological) affecting a person’s ability to carry out a normal activity and to participate fully in study, work and community and social life .”Disability” is an umbrella term covering impairments, activity limitations and participation restrictions .
Currently, more than 1 billion persons with disabilities live around the world (WHO, 2015), thus making them the world’s largest minority (15% of the entire population) . About 95 million (5.1%) children 0-14 years-old live with a disability worldwide, 13 million (0.7%) of them having “severe disability” (Global Burden of Disease) .
The United Nations Convention on the Rights of Persons with Disabilities (CRPD),adopted in 2006, aims to “promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities and to promote respect for their inherent dignity”. It reflects the major shift in global understanding and responses towards disability .
Quality of life is a complex experience influenced by objective conditions in which a person lives (social indicators), subjective response of the person to their life conditions (psychological indicators), the adjustment of expectations and needs of the person with their lifestyle and external influences .
Disability and Health Care
People with disabilities have general health care needs as everyone else – or even more and therefore need access to mainstream health care services. Article 25 of the UN Convention on the Rights of Persons with Disabilities (CRPD) reinforces the right of persons with disability to attain the highest standard of health care, without discrimination .
People with disabilities are particularly vulnerable to deficiencies in health care services. Depending on the group and setting, persons with disabilities may experience greater vulnerability to secondary conditions, co-morbid conditions, age-related conditions, engaging in health risk behaviours and higher rates of premature death . People with disabilities encounter also a range of barriers when they attempt to access health care such is prohibitive costs, limited availability of services, inadequate skills and knowledge of health workers and physical barriers. Thus,uneven access to buildings (hospitals, health centers), inaccessible medical equipment, poor signage, narrow doorways, internal steps, inadequate bathroom facilities and inaccessible parking areas create barriers to health care facilities .
Disability and Oral Health
For a multitude of reasons (e.g. limited capacities in providing self oral care routines, oral breathing, sweetened medication, impaired chewing abilities, associated anomalies of dental structure etc), individuals with disabilities are regarded as highly vulnerable to oral disease .
Poor oral healthnegatively impacts general quality of life, affecting not only physical wellbeing, but also psychological and social wellbeing. There are a number of reasons for that :
- a tendency to avoid social contact as a result of concerns over facial appearance ;
- persistent pain has isolating and depressing effects ;
- dental diseases that affect verbal and non–verbal communication are likely to damage self–image and alter the ability to sustain and build social relationships ;
- dental disease can affect the way a person looks and sounds, with a significant impact on wellbeing; a person whose appearance and speech are impaired by dental disease can experience anxiety, depression, poor self–esteem and social stigma which in turn may inhibit opportunities for education, employment and social relationships (The US Department of Health and Human Services) ;
- poor oral health status has an adverse impact on infection, nutrition, digestion or chewing ;
- even specific protocols for treatment under GA in patients with intellectual disabilities can have a negative impact on QoL- e.g.: in order to avoid potential complications, a tooth with complicated decay needing endodontics followed by complex restoration is more likely to be extracted than restored . But, an extracted upper front tooth in an autistic child will have an obvious negative impact on the patient’s appearance with evident consequences upon an already difficult social integration.
Many clinical studies report that people with disabilities have poorer oral health than the general population, oral diseases being a major health problem for them . They tend to have more missing teeth and fewer fillings than the general population, periodontal disease being also common. These indicate that people with disabilities do not receive dental treatment at the proper time . Thus, Fernandez et al. (2012) reported that 28% of special athletes from New York screened between 2005 and 2008 had untreated caries and 32% had periodontal disease . Schuler et al. (2011) found that 35% of German athletes with disabilities (mean age 25 years) had untreated decay and 43% showed signs of periodontal damage . In Belgium, Leroy et al. (2012) found periodontal signs in 44% of the SO athletes and untreated caries in 22% for a mean age of 33 years . For Romania Vinereanu et al. (2017) reported that the prevalence of caries in SO athletes was 86.7% in 2006 (mean age 15.57 years) and 76.3% in 2016 (mean age 21.45 years). 50.5% of the Romanian SO athletes examined in 2006 exhibited signs of gingivitis. The corresponding proportion for groups 2016 were 73.5% .
The implications of poor oral health are substantial:
- on general health: aspiration pneumonia and major chronic diseases such as cardiovascular disease, diabetes, respiratory disease and stroke ;
- on an individual’s psychological and social health;
- poor oral health can lead to toothache, associated anxiety, difficulty performing daily activities, impaired social interactions and reduced nutritional intake .
As for children, poor oral health can affect their growth and overall health, can restrict their participation in schooling and education and can further limit children’s ability to socialize with confidence and develop social norms and relationships . Contributing factors to poor oral health in children with disabilities and other special care needs are:
- oral conditions – some genetic disorders in young children can cause defects in tooth enamel or hypodontia [14, 15].
- physical limitations – children who cannot chew or move their tongues properly do not benefit from the natural cleaning action of the tongue, cheek and lip muscles [14, 15].
- difficulties in brushing and flossing – children with poor motor coordination such as spinal cord injuries, muscular dystrophy or cerebral palsy may not be able to clean their own teeth or use the usual brushing and flossing methods . In adition, children with intelectual disabilities always have difficulties in self-cleaning and communicating oral health care needs. They also cannot understand the significance of oral cleanliness and tend not to cooperate and even resist toothbrushing, which is a barrier to parental success in helping their children with oral hygiene .
- reduced saliva flow – children who need help drinking may drink less fluid than other children and may not have enough saliva in their mouth to help wash away food particles .
- medications – children using sweetened medications for a long time can get tooth decay. Some anti-seizure medications may cause swelling or bleeding in the gums . Medication used to treat cerebral palsy, seizures and depression or asthma and allergies can cause dry mouth (xerostomia) [15, 17].
- restricted diets – children who have difficulty chewing and swallowing may often eat puréed food which may stick to their teeth .
A child with special health care needs may exhibit any of the following signs when there is an oral health problem: grinding teeth, food refusal or a preference for softer foods, changes in behavior such as touching in or around the mouth, teeth, jaws and cheeks, foul smelling breath or discolored teeth .
Oral pathologies in disabled children may comprise: periodontal disease, overgrowth of gums, caries, malocclusion, damaging oral habits, trauma and injury, tooth anomalies (variations in the number, structure, size and shape of teeth), delayed, accelerated or inconsistent eruption .
Regarding dental caries, many studies report an increased prevalence in children with special health care needs, maximum values ranging from 78.3% to 89.6% [18, 19]. Higher rates of DMF-T with values ranging from 3.5 to 12.51 were also reported [20, 21]. Thus, Reddy and Sharma (2011) founded, for visually impaired children, a prevalence of caries of 40% and DMF-T/dmf-t scores of 1.1/0.2 respectively, while the corresponding figures for children without visual impairment were much lower: 11.5% for prevalence index (Ip) and 0.9/0.5 for DMF-T/dmf-t . Jaber (2011) reported that children with autism exhibited higher caries prevalence (77.0%) and DMFT (1.6) than children in a non-autistic healthy control group (Ip=46%, DMF-T=0.6) . Ivancic et al. (2007) reported the mean DMF-T in disabled and healthy children to be 6.39 vs. 4.76 . Bharati et al. (2012) founded that from 191 disabled children (12 years) caries prevalence was 89.8% and DMFT index was 2.52, while from 203 healthy children prevalence index was 58.6% and DMFT index was 0.61 . In Romania, Vinereanu et al. (2019) reported a prevalence index of 92.6% and a DMF-T value of 8.13±5.69 for a group of 271 Special Olympics athletes ( mean age=19.34 ± 9 years) .
Regarding parodontal status in disabled children, Bharati et al. (2012) showed that the CPI index values were statistically significantly higher in the group of 12-year-old children with disabilities than in the control group . Zietek et al. (2019) reported that prevalence of periodontitis in 150 patients (5-21 years) with Down syndrome was with 14.7% higher than in the healthy controls (100.0 vs. 85.3%; p < 0.001) . For a sample of 80 patients (2-18 years) with cerebral palsy from Brazilia Cardoso et al. (2015) showed that the mean GBI was 22.44% and in the CPI, the prevalence of gingival bleeding, calculus, shallow and deep pockets were 94.73%, 79.62%, 12.90% and 3.22%, respectively .
The mean values for treatment needs, especially pulp treatment needs, is higher in subjects with special health care needs . In Romania, 69.7% of the Special Olympics athletes had restorative index (RI) values below or equal to 10 (Vinereanu et al., 2017). These results are explained by their difficult access and the high costs for treatment in the dental offices. However, through the programs already implemented, the restoration index increased from 10.07 in 2006 to 25.75 in 2016 .
Ways to improve
As for all children but probably even more for children with disabilities, prevention of oral disease is essential. Primary prevention is the simplest and most effective method to avoid complex treatment sessions with all that they involve, to reduce costs and to ease the burden on families and caregivers and ultimately upon society. In addition, the QoL of patients with disabilities will be significantly improved.
A useful idea for providing personalized and therefore more efficient prevention could be the Dental Home concept. Relatively new, it was initially implemented in the USA. The starting point of this concept was a principle ellaborated by the American Academy of Pediatrics (AAP) (1992), stating that medical care of children of all ages is best managed when there is a relationship established between a practitioner who is familiar with the child and the child’s family . This obviously applies to oral care as much as to any other medical field. In children with disabilities, early identification of potential risks and consequences of the child’s general condition and/or medication upon the development and evolution of dentition and oral tissues may give way to early personalized prevention strategies. Efficient primary prevention and early interception of emerging problems would lead to less complex treatment needs, less dental fear, better functionality, better social integration – and lower costs. Thus, Dental Home could contribute to improving the QoL for disabled children [27, 28].
Given the oral health status of children with disabilities in Romania, but also the difficult access to specialized medical services, it would be desirable for the Dental Home system to be progressively introduced and implemented in our country, initially at a small, individual/community level, then gradually growing to a larger scale. For this purpose, information and education programs for families, caregivers and medical assistants need to be initiated and developed. As a step in this direction, the Dental Home concept is being introduced to dental professionals by the Erasmus+ project ”Oral Special Care Academic Resources”(OSCAR).
Regarding secondary and tertiary prevention, we need to provide policies and treatment for decreasing the number of missing teeth, such as maintenance management for people with a disability or an additional insurance system because people with disabilities develop worse oral health at a younger age than do non-disabled people. For improving dental accessibility, mobile care units are needed, as well as an administrative system such as the expansion of the existing workforce of a mobile dental care team .
In order to achieve the purpose of ensuring equal rights and opportunities for the disabled persons, a series of ‘legal instruments’ were developed internationally:
- United Nations Convention on Rights of Persons with Disabilities 2006;
- Invalidity, Old-Age and Survivor’s Benefits Convention 1967;
- The European Disability Strategy 2010-2020 etc.
Also, at national level governors are backed up by specific legislation against discrimination on grounds of disability .
- Disabled peopled have a poor health-related quality of life.
- Oral health of disabled persons is severely affected by patients’ inability to care themselfs and by the difficult access to specialized medical services.
- Prevention is the safest and cheapest method to increase the quality of life for these persons and Dental Home can be a big step forward to improve it.
Note: This research is part of 2019-1-RO01-KA202-063820 Erasmus+ Project „Oral Special Care Academic Resources” (OSCAR)
Conflict of interests: None
- World Health Organization. World report on disability. 2011: 1-24.
- Zheng X., Cheng G., Song X. et al. Twenty-year trends in the prevalence of disability in China. Bulletin of the World Health Organization 2011; 89: 788-97. doi:10.2471/BLT.11.089730.
- Disabled World . www.disabled-world.com. Published: 2009-12-23 : (Rev. 2019-04-21).
- Baciu E.L., Lazăr T.A. Between equality and discrimination: disabled persons in Romania. Transylvanian Review of Administrative Sciences. No 51 E/2017:5-19. doi: 10.24193/trans.51E.1.
- Bakula M.A., Kovacevic D., Sarilar M. et al. Quality of life in people with physical disabilities. Coll Antropol 2011; 35 Suppl 2(2): 247-53.
- Lee J.Y., Lim K.C., Kim S.Y. et al. Oral health status of the disabled compared with that of the non-disabled in Korea: a propensity score matching analysis. PloS One 2019. doi: 10.1371/journal.pone.0208246.
- Zhou N.I., Wong H.M., Wen Y.F., McGrath C. Oral health status of children and adolescents with intellectual disabilities: a systematic review and meta-analysis. Developmental Medicine & Child Neurology 2017; 59: 1019-26. doi: 10.1111/dmcn.13486.
- Schnabl D., Guarda A., Guarda M. et al. Dental treatment under general anesthesia in adults with special needs at the University Hospital of Dental Prosthetics and Restorative Dentistry of Innsbruck, Austria: a retrospective study of 12 years. Clinical Oral Investigations 2019, 23: 4157-62. https://link.springer.com/article/10.1007%2Fs00784-019-02854-8.
- Fernandez JB, Lim LJ, Dougherty N, LaSasso J, Atar M, Daronch M: Oral health findings in athletes with intellectual disabilities at the NYC Special Olympics. Spec Care Dentist. 2012 SepOct: 32(5):205-9.
- Schüler IM, Kaschke I, Heinrich-Weltzien R: Special Olympics Special Smiles: Oral healthcare for people with special needs. EADPH 16th annual meeting, Rome 2011. http://www.eadph.org/downloads/meetings/2011.pdf, page 48.
- Leroy R, Declerck D, Marks L: The oral health status of Special Olympics athletes in Belgium. Community Dent Health. 2012 Mar; 29(1):68-73.
- Vinereanu A., Garret-Bernardin A., Munteanu A., Bratu A.M., Luca R.. Oral health of athletes with intellectual disabilities in Romania: evolution over a decade (2006-2016). Medicine in evolution 2017; XXIII(3): 288-94.
- Wilson N.J., Lin Z., Villarosa A. et al. Countering the poor oral health of people with intellectual and developmental disability: a scoping literature review. BMC Public Health 19, 1530 (2019). https://doi.org/10.1186/s12889-019-7863-1.
- Health and safety notes California childcare health program. Oral health for children with disabilities and special needs.
- Bharathi M Purohit, Abhinav Singh. Oral health status of 12-year-old children with disabilities and controls in Southern India. WHO South – East Asia Journal of Public Health 2012; 1(3): 330-8.
- Liu Z., Yu D., Luo W. et al. Impact of oral health behaviours on dental caries in children with intellectual disabilities in GuangZhou, China. Int J Environ Res Public Health 2014, 11(10): 11015-27. doi: 10.3390/ijerph111011015.
- Brush up on oral health. Oral Health and children with disabilities. eclkc.ohs.acf.hhs.gov/publication/oral-health-children-disabilities.
- Reddy K., Sharma A. Prevalence of oral health status in visually impaired children. J Indian Soc Pedod Prev Dent 2011; 29: 25-7.
- Shyama M., Al-Mutawa S.A., Morris R.E. et al. Dental caries experience of disabled children and young adults in Kuwait. Community Dent Health 2001; 18: 181-6.
- Ivancic Jokic N., Majstorovic M., Bakarcic D. et al. Dental caries in disabled children. Coll Antropol 2007; 31: 321-4.
- Kamatchy K.R., Joseph J., Krishnan C.G. Dental caries prevalence and experience among the group of institutionalized hearing impaired individuals in Pondicherry – a descriptive study. Indian J Dent Res 2003; 14: 29-32.
- Jaber M.A. Dental caries experience, oral health status and treatment needs of dental patients with autism. J Appl Oral Sci 2011; 19: 212-17.
- Vinereanu A., Munteanu A., Baltag I. et al. Oral health of mentally challenged Romanian athlets, still a chalenge in 2018. Revista Română de Medicină Dentară 2019; XXII, 3: 416 – 26.
- Zietek M., Kaczmarek U. Oral hygiene and periodontal status in children and adolescents with Down syndrome. Nowa Stomatol 2019; 24(1): 20-6.
- Cardoso A.M.R., Gomes L.N., Silva C.R.D. et al. Dental caries and periodontal disease in Brazilian children and adolescents with cerebral palsy. Int J Environ Res Public Health 2015; 12(1): 335-53. doi.org/10.3390/ijerph120100335.
- AAP 1992
- Nowac A.J., Casamassimo P.S. The dental home. A primary care oral health concept. JADA 2002 January, 133: 93-98.
- Vinereanu A. et al. Dental behaviour of mentally challenged Romanian children. 9th Congress EAPD, Dubrovnik, 2008.