The role of rehabilitation dentistry.

People with disability face many problems in obtaining adequate dental care both in terms of daily oral hygiene and routine professional treatment. Physical barriers, financial limitations, poor motivation, and lack of qualified care providers are some of the difficulties that must be overcome.

To enable people who are disabled to participate in oral health services requires a concerted effort by many different rehabilitation disciplines. In this process, the other rehabilitation professions must develop a greater awareness of dental problems and dental professionals must learn to work in close coordination with members of the rehabilitation team. Such interaction will enhance the climate for successful rehabilitation, resulting in effective consumer education, better trained professional and nonprofessional care-givers, efficient clinical services, and, ultimately, the improved health and function of the disabled individual.

Oral Health Problems

Disabling conditions frequently are associated with severe oral disease and dysfunction of the craniofacial complex. Multiple etiological factors play a role; some are inherent in the disability, and others are untoward side effects. For example, the chromosomal abnormality of Down syndrome is associated with a high susceptibility to severe early-onset periodontal disease and premature loss of teeth in affected individuals (Reuland-Bosma & van Dijk, 1986). People with neurological and neuromuscular disorders, such as cerebral palsy, mental retardation and closed head injuries are prone to salivary incontinence (drooling), and severe bruxing (tooth grinding) habits that may result in excessive wear of teeth and injury to the temporomandibular joint (Richmond, Rugh, Dolfi, et al., 1984). Trauma to the dentition is of concern in people with seizure disorders. Severe weight loss, as in cancer, or loss of muscle tone, due to stroke, or other neuromuscular disorders may have adverse effects on the abiity to wear dentures.

Drug-induced oral changes are of particular significance in the etiology of dental disease in disabled people. The effects of medication may be specific as in the case of Dilantin caused hyperplasia (abnormal increase in number of normal cells) of the gum tisse, or more general such as the head and neck manifestations of tardive dyskinesia (late appearing involuntary movement) associated with antipsychotic medications. Reduction in salivary secretion by prescribed medications is of significant concern. Over 400 drugs have been identified as causing hyposalivation and xerostomia (dry mouth) (Sreebny & Valdini, 1987). Common medications in this group include antidepressants, antipsychotics, sedatives, hypnotics, antihistamines, anticholinergics, antiparkinsonism agents, antihypertensives, and diuretics. Reduced salivary flow greatly increases the risk for dental caries, particularly gumline decay, periodontal disease, yeast infections, and other oral lesions. The adverse effects of xerostomic medications were substantiated in a recent comparative study of subjects with and without mental illness (Stiefel, Truelove, Menard, et al., 1990).

The significance of preventing dental disease and maintaining oral health in people with disability cannot be overemphasized. Oral disease caused by dental neglect and the ensuing need for extensive treatment may place individuals who are severely disabled at serious additional medical risk. For people with major chronic medical disorders, advanced dental disease and its required treatment may have life-threatening consequences. Complex dental treatment resulting from lack of regular dental care increases costs, time lost from work, and impedes the rehabilitation process. For many people with disability, the oral cavity takes on critical importance in terms of psychological significance and physical function. The mouth has been termed the lifeline for the person who is disabled, the center of the personality in the absence of one or more functioning faculties (Kimmelman, 1989). The mouth may be the only part of the body over which the person retains voluntary control and the jaws and teeth may serve as the only functioning extremity. Every effort must therefore be made to save the natural teeth. If the natural dentition is lost, the person with a severe physical or mental impairment may not be able to manage a dental prosthesis to aid in eating, verbal communication, device-activated communication, and independent management of other tasks. Edentulism (having no teeth) is no longer acceptable to disabled people and their families. The disabled population has the same expectations regarding a functioning dentition as the nondisabled population.

Access to Dental Care

Although in recent years the oral health of the population as a whole has improved significantly, people with disability continue to have serious dental problems and remain underserved in dental care.

A recent Dental Education in Care of the Disabled (DECOD) study of 106 RSA-supported rehabilitation agencies and organizations serving people with functional disabilities in Washington, Alaska, Oregon, and Idaho revealed significant dental needs. Of 77 groups responding, 88.3 percent stated their clients had unmet dental treatment needs, which suggests ongoing oral and dental disease. Financial factors were identified as a barrier to care by 86.6 percent of responding agencies, 63.4 percent cited barriers directly associated with the disability (i.e., can't find a dentist trained to work with disabled patients, difficulty with transportation to a dentist who can treat them, lack of motivation by their general caregiver). Fear of dental procedures was identified as a barrier to care by 34.1 percent of respondents, substantially higher than the prevalence of 20 percent reported for dental fear for the population at large and, very likely, a reflection of lack of regular dental care and poor past dental experiences. The large majority, 80.2 percent, of the agencies stated it was important or very important for dentists to have specialized training to meet the unique needs of their clients (Stiefel, Truelove & Mandel, 1990).

Similar barriers to dental care are evident in other areas of the United States. In a survey of five regional centers for people with developmental disabilities in California, almost 50 percent of responding parents reported difficulties, including locating dentists, transportation andpayment for care for their disabled children. Problems in accessing dental care tended to be associated with less frequent dental and an extraction at the last dental visit, again suggesting unchecked dental disease (Finger & Jedrychowski, 1989).

Facilitating access to dental services for the person with disability requires support at all levels, including locating appropriate care providers, assisting with transportation or arranging for mobile dental services, determining availability of financial resources, and overcoming fear and anxiety. Rehabilitation counselors, theraphists and case workers can provide valuable assistance in the coordination of dental care for people who are severely disabled.

The majority of people with disability can be treated in the regular dental office. A number of communities have listings of dental practitioners who are available to treat people with disability. These directories usually include such pertinent information as dentists' specialty and experience in treating patients with disability and office wheelchair accessibility (Stiefel, Shaffer & Bigelow, 1981; Siegal, 1986). Inquiries regarding the availability of a referral directory should be addressed to the local State Dental Association. People with complex conditions should be served by care providers who have had appropriate advanced training and are sensitive to the needs of special patients. A growing number of dentists and dental hygienists have gained experience treating people with disability either as part of their regular dental training, through residency programs or an advanced level course, such as the DECOD Program at the University of Washington, Seattle, WA. To meet the needs of disabled people who are not ambulatory, an increasing number of dental practitioners have mobile dental equipment and make house calls or visits to long-term care facilities (Casamassimo, Coffee & Leviton, 1988).

Finding financial resources and low-cost dental services can be a major challenge to the patient and the patient's counselor. Benefits for dental care under the Medicaid system vary from state to state and Medicare does not cover routine dental procedures. In some areas, dentists have agreed to participate in reduced fee programs or donate their services through projects such as DDS (Donated Dental Services) developed by the National Foundation of Dentistry for the Handicapped. Other sources for low-cost care are dental schools with special patient care programs and community clinics (Stiefel, Truelove & Mandel, 1984; Porter & Casamassimo, 1986). Additional resources worth exploration include fraternal groups and benevolent organizations. Young disabled patients may qualify for financial assistance from the Grottoes of North America, a Masonic order whose major philanthropic thrusts is in this specific area of care.

Patients with disabilities may have difficulty in complying with scheduled dental appointments. Those who have not had regular dental care or have had unpleasant dental experiences may be fearful and reluctant to see the dentist. The availability of a caseworker or other support person to accompany such patients to the office for initial visits provides the support necessary to facilitate fear reduction. Over time, with appropriate behavior modification and quality care, fearful patients often become excellent dental patients.

Patient Assessment

The mouth is an integral part of the body and dental treatment can affect and be affected by the patient's general physical and mental status. A thorough health history is an important prerequisite to safe treatment. For the patient with a physical or mental disability, it is particularly important to gain full information about problems or limitations that impact dental care. Areas of special concern include allergies, heart defects, prosthetic joints, and conditions that necessitate prophylactic antibiotics prior to dental treatment. Knowledge of major systemic disorders such as diabetes, infectious diseases and current medications may dictate modifications in the delivery of dental care.

A disability profile should be part of the dental workup. It should focus on disability-related limitations and requirements, including etiology and time of onset, ability to tolerate proposed dental treatment, communication deficits, special positioning needs, indications for adaptive aids, support persons and the legal guardian. Consultation by the dentist with the patient's physician, counselor and other members of the rehabilitation team will help assure treatment in a safe, systematic and expeditious manner.

Effective communication with the patient and/or responsible person is a key component in patient assessment and management. For example, the person who is profoundly deaf may require the presence of a sign language interpreter. Those with mental disabilities (mentally retarded, psychiatric diagnosis, brain injured) or language deficits require a responsible person available to provide the patient's medical, dental and social history.

Preventive, Restorative and

Rehabilitation Dental Care

Dental caries and periodontal disease are largely preventable through daily oral hygiene and through periodic professional care. Many people with disability have physical or mental impairments that limit them in effectively performing oral hygiene procedures. They may be completely dependent on others for daily home care which unfortunately tends to be a low priority task for direct caregivers. Compliance in providing oral personal hygiene needs to be assured through staff inservice training reinforced at frequent intervals.

The high incidence of dental disease in people with disability warrants frequent mouth screening evaluation by daily caregivers and regular professional care. More frequent dental recall visits are often necessary and may need to be as frequent as every 3 months.

Advances in dental treatment methods hold considerable promise for improving the oral health of people with disability. Newer preventive therapies using disease-specific antimicrobial agents have proven effective and useful as adjuncts to professional dental care. For people who are disabled, the usual protocol of application of such agents may need to be modified. Thus, a recent study supported by a grant from the National Institute on Disability and Rehabilitation Research has shown that, in lieu of oral rinsing, a mouthwash of 0.12 percent chlorhexidine gluconate (Peridex [R] Procter & Gamble) can be successfully applied to the teeth with a sponge swab (Toothette, Halbrand, Inc.) and when applied once daily in this manner, resulted in significant reductions in plaque and gingivities (Stiefel, Truelove, Chin, et al., 1990). The study involved 80 adults with severe physical and mental disabilities who

participated at 11 different rehabilitation settings, including long-term care facilities, supported employment and independent living. The protocol was well accepted by subjects and staff. Improved dental health was positively correlated with improved appearance, smile and mouth odor. People who reported good physical health tended not to have dental problems, to rate quality of life highly, to report improvement in smile, and to perceive no adverse effects from the teeth (Stiefel, Truelove, Chin et al., 1990).

For people at high risk for dental disease, particularly dental caries, daily use of topical fluoride is also recommended, with the protocol of choice depending on the patient's condition and ability to empty the mouth (Yamagata, Stiefel & Horike, 1983).

While the dental operatory remains the place of choice for extensive treatment, the advances in mobile dental equipment make onsite care an attractive alternative for routine diagnostic and preventive services for people with severe disabilities. Thus, oral screening examinations and professional cleaning of the teeth can be readily conducted in group homes, independent living centers and supported employment workshops. Similarly, oral hygiene procedures can be effectively incorporated into the daily schedule at group residences and supported work situations with monitoring by counselors or nursing staff.

The construction of adaptive oral devices requires close collaboration of health disciplines including occupational therapy, orthotics, biomedical engineering, and dentistry. These devices can significantly enhance the level of independence of people with impaired function of the upper extremities. People who are quadriplegic may require a bitestick to perform many tasks. To preserve the health and function of the teeth and orofacial structures these appliances should be custom fabricated. They should provide full occlusal contact and distribute the biting forces over the maximum area of tooth surface (Mulligan, 1983; O'Donnel, Yen & Robinson, 1985).

A variety of adaptive aids can also be used to foster independence in the performance of daily oral hygiene. These range from an elaborate commercially available appliance such as the Sunbeam Dental Care System for the Disabled (Northern Electric Company), developed by the University of Mississippi (Fitchie, Reeves, Comer, et al., 1988), to simple items such as rubber balls, bicycle grips, wooden spoons, and rods that serve to enlarge or extend handles on tooth brushes and floss holders.

Patients with limited manual dexterity may also benefit from use of advanced types of rotary electric tooth brushes, such as the Interplak [R] instrument. For patients with swallowing defects, who are at risk for aspiration of fluids, toothbrushes with suctioning devices are available; Plak-Vac (Trademark Corporation) and Vac U Brush (ora genics) are two examples.

Another area of interest is the increasing use of tooth colored restorative materials that allow for aesthetic and relatively economic restoration of lost tooth structure. In addition, the advent of tooth implants to replace missing teeth may offer viable treatment options for patients with disability who must have nonremovable dental prostheses. The adaptation of these materials and procedures to meet the complex oral conditions associated with some disabilities requires further research.

Professional Training

The importance of educating dental professionals in the management of people with disabilities has been clearly recognized. By increasing the scope of practitioner knowledge, clinical competence and confidence, access to dental services and the quality of care for the disabled will improve. The American Association of Dental Schools has published curriculum guidelines for teaching dentistry for patients with disabling conditions (Casamassimo, Henson, Posnick, et al., 1985). However, the scope of such teaching programs at the predoctoral level varies widely, with didactic teaching hours ranging from 2-56 hours and clinical teaching from 0-144 hours (Wright & Friedman, 1987). Although dental and dental hygiene students usually receive an introduction to special patient care as part of their basic education, their preparedness to treat more severely disabled patients in community and nontraditional settings is generally limited (Cohen, LaBelle & Singer, 1985; Stiefel, Truelove & Jolly, 1987).

A need for postgraduate training in rehabilitation dentistry is evident. Based on more than 10 years of experience by the DECOD Program at the University of Washington, it appears that a range of training options must be offered. Training opportunities should include the self-instructional mode, short didactic and clinical participation courses and long-term training of 6 months and longer for the dental professional who wishes to dedicate his or her career to special patient care. Support from the Rehabilitation Services Administration helped to establish experimental and innovative training projects in dentistry. Categorical funding for training in rehabilitation dentistry is essential to maintain such programs in the future.

In view of the interdependence of dentistry and other disciplines in rehabilitation services, each discipline must become more familiar with the basic principles and goals of the other professions, and all must be sensitized to the needs of the consumer who is disabled. Such knowledge and awareness are best acquired through inclusion of an interdisciplinary core component in the curriculum of each of the rehabilitation disciplines. This approach has been tested and found highly valuable (Stiefel & Truelove, 1985; Holtzman, Bomberg, Berkey, et al., 1988). For example, numerous disciplines participate in the teaching of the DECOD courses at the University of Washington: physical therapists from the Department of Rehabilitation Medicine demonstrate wheelchair transfer techniques, vocational counselors discuss psychosoical issues of disability, physiatrists lecture on various disabling conditions, nutritionists present concerns in nutrition, and speech pathologists provide dental professionals with basic information on speech and swallowing disorders. Furthermore, the inclusion in these courses of instructors who are disabled has proven highly effective.

Conversely, dentistry must also increasingly reach out to other disciplines. Thus, our dental faculty has provided dental information in several interdisciplinary courses on care of special populations through the School of Nursing and the School of Medicine. An interdisciplinary curriculum should include not only didactic instruction but also opportunities for clinical observation and interaction between disciplines. By building a strong foundation in interdisciplinary care, optimum benefits can be offered to the consumer with a disability.

Dentistry clearly has an integral role to play in most aspects of rehabilitation, including training and education, community outreach, and clinical services. In fulfilling this mission, dentistry makes an essential contribution to the quality of life for people who are disabled.

Resources

1) Academy of Dentistry for the Handicapped; Executive Director: Dr. Paul Van Ostenberg; 211 East Chicago Avenue, Chicago, IL 60611. Telephone: [phone].

2) Dental Education in Care of the Disabled (DECOD); Director: Dr. Doris J. Stiefel; School of Dentistry, SC-63, University of Washington, Seattle, WA 98195. Telephone: [phone].

3) National Federation of Dentistry for the Handicapped; Executive Director: Dr. Larry Coffee; 1600 Stout Street, Suite 1420, Denver, CO 80202. Telephone: [phone].

Bibliography

1) Casamassimo, P.S., Henson, J., Posnick, W., and Tesini, D. (1985). Curriculum Guidelines for Dentistry for the Person with a Handicap. Journal of Dental Education 49, 118-122.

2) Casamassimo, P.S., Coffee, L.M. and Leviton, F.J. (1988). A Comparison of Two Mobile Treatment Programs for the Housebound and Nursing Home Patient. Special Care in Dentistry 8, 77-81.

3) Cohen, L., LaBelle, A. and Singer, J. (1985). Educational Prepration of Hygienists Working with Special Populations in Nontraditional Settings. Journal of Dental Education 49, 592-595.

4) Fitchie, J.G., Reeves, G.W., Comer, R.W., Gatewood, R.S., Campbell, E.A., and Rommerdale, E.H. (1988). Oral Hygiene for the Severely Handicapped: Clinical Evaluation of the University of Mississippi Dental Care System. Special Care in Dentistry 8, 260-264.

5) Holtzman, J.M., Bomberg, T.J., Berkey, D.B., and Entwistle, B.A. (1988). Training Dental and Nondental Professionals Together: the Oral Health Gerontology Fellows Program. Special Care in Dentistry 8, 54-57.

6) Kimmelman, B.B. (1989). The Need for and Ability of Dental Services among People with Severe Disabilities. Special Care in Dentistry 9, 10-11.

7) Mulligan, R. (1983). A Physiologic Bitestick Appliance for Quadriplegics. Special Care in Dentistry 3, 24-29.

8) O'Donnel, D. Yen, P.K.J. and Robinson, W. (1985). A Mouth-controlled Appliance for Severely Physically Handicapped Patients. British Dental Journal 159, 186-188.

9) Porter, T.C. and Casamassimo, P.S. (1986). The Status of the Handicapped and Medically Compromised as Pre-doctoral Teaching Patients. Journal of Dental Education 50, 538-539.

10) Reuland-Bosma, W. and van Dijk, L.J. (1986). Periodontal Disease in Down's Syndrome: a Review. Journal of Clinical Periodontology 13, 64-73.

11) Richmond, G., Rugh, J.D., Dolfi, R. and Wasilewsky, J.W. (1984). Survey of Bruxism in an Institutionalized Mentally Retarded Population. American Journal of Mental Deficiency 88, 418-421.

12) Siegal, M.D. (1986). Usefulness of a Statewide Referral Directory of Dentists Found Willing to Treat Disabled Persons. Journal of Public Health Dentistry, 46, 161-163.

13) Sreebny, L.M. and Valdini, A. (1987). Xerostomia, a Neglected Symptom. Archives of Internal Medicine, 147, 1333-1337.

14) Stiefel, D.J., Shaffer, S.M. and Bigelow, C. (1981). Dentists' Availability to Treat the Disabled Patient. Special Care in Dentistry, 1, 244-249.

15) Stiefel, D.J., Truelove, E.L. and Mandel, L.S. (1984). Treatment Needs and Care Delivery in a Graduate Training Program of Dentistry for the Disabled. Special Care in Dentistry 4, 219-225.

16) Stiefel, D.J. and Truelove, E.L. (1985). A Postgraduate Dental Training Program for Treatment of Persons with Disabilities. Journal of Dental Education 49, 85-90.

17) Stiefel, D.J., Truelove, E.L. and Jolly, D.E. (1987). The Preparedness of Dental Professionals to Treat Persons with Disabling Conditions in Longterm Care Facility and Community Settings. Special Care in Dentistry 7, 108-113.

18) Stiefel, D.J., Truelove, E.L., Menard, T.W., Anderson, V.K., Doyle, P.E. and Mandel, L.S. (1990). A Comparison of the Oral Health of Persons with and without Chronic Mental Illness in Community Settings. Special Care in Dentistry 10, 6-12.

19) Stiefel, D.J., Truelove, E.L., Chin, M.M., and Mandel, L.S. (1990)> Chlorhexidine Swabbing in Disabled Rehabilitation Groups: Effects on Oral Health. J. Dent. Res. (Specs. Iss.) 69, 179.

20) Stiefel, D.J., Truelove, E.L., Chin, M.M., and Mandel, L.S. Chlorhexidine Swabbing as an Oral Care Procedure for Disabled Populations. 10th Congress, Internatl. Assoc. Dentistry for the Handicapped, Sept. 6, 1990.

21) Stiefel, D.J., Truelove, E.L. and Mandel, L.S. (1991). Perceived Barriers vs. Dental Care Availability for Persons with Disabilities. J. Dent. Res. (Spec. Iss.) 70, 337.

22) Wright, G.Z. and Friedman, C.S. (1987). Dentistry for the Handicapped: a Survey of Predoctoral Teaching Programs. Special Care in Dentistry, 7, 62-64.

23) Yamagata, P.B., Stiefel, D.J. and Horike, J. (1983). Aids to a Healthy Mouth: Unit E, Oral Care for Persons with Disabilities, University of Washington, Seattle, WA, pp 9-13.

Dr. Stiefel is Director, Dental Education in Care of the Disabled (DECOD), and Associate Professor, Department of Oral Medicine, School of Dentistry, University of Washington; Past-President, Academy of Dentistry for the Handicapped (1988-1990).

Dr. Truelove is Associate Professor and Chairman, Department of Oral Medicine and Co-Director, DECOD, University of Washington.