Joseph Shapira, DMD, Jacob Efrat, DMD, Douglas Berkey, DMD, MPH, MS, Jonathan Mann, DMD, MSc

Dental health profile of a population with mental retardation in Israel

The dental status and treatment needs of Israeli children and adults with mental retardation were studied in a random sample of 387 subjects. Four levels of mental retardation were represented: (1) educable (n = 70), (2) trainable (n = 92), (3) with mental retardation and be- havioral problems (n = 106), and (4) with mental retardation and severe physical handicap (n = 119). The total age-adjusted DMF-T was 12.78 and differed significantly by be- havioral group (p e 0.001); the M-T was 10.70 for the educable group compared with 5.52 for the group with mental retardation and severe physical handicap. Total treatment needs included a participant mean of 3.32 for restorations and 0.61 for extractions. Institutions having den- tal clinics had higher participant mean DMF-T, D-T, M-T, and F-T values (p e 0.05) compared with those insti- tutions which had no clinics ( 1 6.04 vs. 9.74; 5.1 7 vs. 5.06; 9.45 vs. 4.16; 1.41 vs. 0.52). Age-adjusted CPlTN scores significantly differed by behavioral group; the group with mental retardation and severe physi- cal handi-cap had the highest CPITN 3 category mean score of 2.93 com- pared with X = 1.89 for the educable group; however, the educable group had the most sextants with no teeth (x= 2.48). Findings confirm high dental morbidity and significant oral health differences by behavior group, age, and dental clinic status. Advanced training is recommended for dental providers and the staffs of institutions to enhance oral health outcomes.

he dental literature is replete with reports on the relatively high dental morbidity, low den-

tal service utilization, and question- able patterns of dental treatment interventions pertaining to handi- capped individuals and especially those with mental retardation (MR). Variables such as age, degree of men- tal retardation, institutionalization, and oral hygiene status have been shown to influence the prevalence and severity of oral disease, dental access, and care patterns in patients with MR.l

A lower caries prevalence has been reported among institutional- ized individuals with MR as com- pared with the non-institutionalized and healthy controls. Nearly 30 years ago, individuals with severe MR had lower DMF-T scores than the train- able or educable population with MR in all age groups2 This finding may have been related to variables associ- ated with the institutional status of these individuals. The impact of insti- tutionalization upon the oral health status of individuals with mental handicaps is a relevant current dental research concern. Have dental mor- bidity and related concerns found in the MR population changed in the last several decades as a result of de- institutionalization and normaliza- tion processes of the late 1970’s?

Nowak3 reported for the first time on the effect of the normalization pro- cess on the oral conditions of handi- capped persons in the United States. Data were analyzed on a total of 2218 non-institutionalized individuals with mental handicaps and aged 16

years and older, who were treated by dentists affiliated with the National Foundation of Dentistry for the Handicapped. A DMF-T of 13.85 was found for those residing in a fluori- dated community, and 15.48 for those in a non-fluoridated community. The DMF-T for the control group of healthy individuals 16 years and older was 14.9. The missing (M) rates were higher than either the decay (D) or filled (F) rates, and in all cases, the DMF-T increased with advancing participant age, suggesting that the teeth of individuals with various han- dicapping conditions were more like- ly to be extracted than to be restored.

Forsberg4 in Sweden studied the prevalence of caries among 100 chil- dren (3-17 years old) with severe MR, and found it lower than the healthy controls. The children living in insti- tutions had significantly lower mean caries values than the non-institution- alized MR group and respective con- trols. The author attributed this find- ing partially to more closely con- trolled diets with fewer intakes of carbohydrates between meals. Gingi- vitis was significantly higher among children with severe MR, and the children with Down Syndrome dis- played the most extensive gingivitis.

In Germany, Pieper5 examined a group of 199 non-institutionalized handicapped individuals aged 17-64, most of whom were ”mentally sub- normal.” The mean DMF-T values ranged from 17.4 in the 17-24-year- old age group to 26.9 in the 55-64- year-old age group. In all age groups, the F-T component was less than 20%, tooth loss increased rapidly with age,

SCD Special Care in Dentistry, Vol18 No 4 1998 149

Table 1. Age adjusted means of DMF-T by behavior groups.

D-T M-T F-T DMF-T ~ - ~ -

Patient Category N X X X X ~ ~ ~ ~ ~~ ~~ ~

Educable 70 5.31 10.70 1.51 17.52

Trainable 92 5.64 6.57 1.13 13.34

MR & SPH 119 4.65 5.52 0.78 10.94

MR & BP 106 4.96 5.61 0.66 11.22

Total 387 5.09 6.73 0.96 12.78

ANCOVA NS p i0.001" NS p < 0.001*

* Significant differences were found between the educable patients and each of the other patient categories, by ANCOVA with Bonferroni correction.

and a high prevalence of periodontal disease was evident in the dentate participants ( P g . , 49% were in need of scaling and 34% were in need of com- plex periodontal treatment).

needs of 194 Irish individuals attend- ing institutions for the handicapped. Among 47 patients in one institution, with a mean age of 30 (age range, 21- 50), the DMF-T was 19.1, with the greatest treatment needs identified as extractions and three-surface fillings. In another institution, among 43 patients with a mean age of 12.1 (age range, 7-17), the mean DMF-T was 3.2 and the mean def-t was 2.5. The treatment needs consisted mainly of one- to two-surface restorations, with few extractions.

Pia Gabre7 compared the dental health status of 132 Swedish adults with MR in 3 different living arrange- ments: Forty-two lived in an institu- tion, 50 lived in less restrictive inte-

Holland6 assessed the dental

grated units, and 40 lived at home. A higher prevalence of caries was found in patients living in integrated units than in those residing in the more restricted institution. In con- trast, periodontal status and loss of alveolar bone were more pronounced for patients living in the institution compared with those living in inte- grated units or at home. These perio- dontal results are in agreement with Tesini's findings of 1981.8 However, the findings on decayed teeth were considerably lower than reported in a German study by Pieper5, who reported a higher number of missing teeth found among the subjects living in institutions.

In the Nordic countries, the gener- al policy goal for persons with dis- abilities is their virtual integration into general society. However, Haavio9 found that individuals with MR in Scandinavian countries received less dental care than the rest

of the population. The treatment con- sisted mainly of extractions, due in part to inefficient recall systems and practical difficulties associated with treatment situations.

In Israel, in two controlled studies involving institutionalized pre-adoles- cents and adults with MR and Down Syndrome (DS),IU,." periodontal treat- ment needs and caries levels were evaluated and compared with those of healthy controls. A striking difference between the patients with MR and healthy controls was reported. Extrac- tions were carried out more frequent- ly for the MR individuals. Children with MR had higher CPITN scores than those with DS or healthy chil- dren, and adults with MR or DS had higher CPITN scores as compared with healthy controls.

have reported that de-institutional- ization of individuals with MR has had a variable impact upon their oral health status. Caries rates may be- come more similar to those of healthy populations, yet non-institutionalized individuals with MR may have also received more extractions and fewer restorations, and exhibit more perio- dontal d i ~ e a s e " ~ ~ ~ ' ~ J ~ than institu- tionalized patients. This may be due in part to difficulties in finding a den- tist who treats patients with disabili- ties, as well as to physical access to dental offices. Also, subjects may be living in a less supervised environ- ment with poor dietary control and lack of supervision of oral h ~ g i e n e . ~ , ~

As a result of a growing concern about the oral health of patients with mental retardation in Israel, the

To summarize, numerous studies

Table 2. Age-adjusted means for dental care treatment needs by behavior groups.

Fissure Sealants Restorations Crowns/Pontics Root Canal Fillings Extraction ~ - - - ~ Group N X X X X X

Educable 70 1.05 3.52 0.28 0.04 0.71

Trainable 92 1.75 3.59 0.11 0.02 0.37

MR & SPH 119 0.87 2.95 0.30 0.04 0.78

MR & BP 106 1.16 3.37 0.19 0.02 0.56

Total 387 1.16 3.32 0.22 0.03 0.61

ANCOVA p < 0.05 NS NS NS "5

150 SCD Special Care in Dentistry, Vol 18 No 4 1998

Table 3. Mean dental care treatment needs bv age grouDs*.

Fissure Sealants One-surface Restorations Two or More Surfaces All Restorations

Age X+. SD xf SD %?+ SD x + S D

3-12 3.56 c 4.20 2.46 c 2.88 0.61 c 1.22 3.07 c 3.15 13-20 2.69 * 3.90 3.11 * 3.06 0.52 f 1.11 3.63 f 3.70 21-40 0.23 i 1.18 3.18 i 2.91 0.70 i 1.23 3.87 * 3.38

2.39 + 2.49 > 40 0.00 c 0.00 1.79 k 1.99

Total 1.16 * 2.86 2.69 c 2.78 0.62 c 1.12 3.32 c 3.27

Significance** p < 0.001 p < 0.001 NS p < 0.005

0.60 k 0.92

Pontic Crown Root Canal Fillings Extraction

Age X* SD x i S D xi SD x i S D

0.00 c 0.00

0.01 f 0.10

3-12 0.02 i 0.15 0.87 c 1.86

13-20 0.00 f 0.00 0.10 2 0.39

0.24 * 0.82

0.17 c 0.54

21-40 0.01 f 0.12 0.16 f 0.66 0.04 f 0.19 0.82 c 2.27

> 40 0.04 c 0.31 0.05 f 0.26 0.05 f 0.21 0.88 c 1.63

0.61 i 1.69 Total 0.02 * 0.18 0.20 c 0.82 0.03 * 0.17

Significance'" NS p < 0.001 NS p < 0.005

* N=387. ** One-way ANCOVA.

Ministry of Labor and Welfare fund- ed an epidemiologic dental study to investigate the oral health status and dental needs of this population. The study was designed to identify base- line needs intended to prompt oral health status improvements for this high-risk population.

Materials and methods According to government records, Israel has about 5000 institutionalized children and adults with mental retardation living in 40 institutions. Another 900 individuals with "sub- normal mentality" live in the com- munity in hostel-type accommoda- tions, representing a transitional phase toward mainstream living.

Data on age and sex distribution, severity of retardation, and physical limitations were compared between persons in residential settings and those in institutions. No substantial statistical differences were found between those institutions having more than 100 individuals and those having fewer than 100. Therefore, for convenience, only those housing

more than 100 individuals were cho- sen. A randomized cluster sample was used. Eleven institutions were sampled, which included more than 1500 subjects, 414 of whom were ran- domly selected to facilitate placement of 25-35 subjects in each of 16 statisti- cal groupings or cells. Data were ulti- mately collected on 387 of these sub- jects.

Cells were comprised of four lev- els of mental retardation-educable (n = 70), trainable (n = 92), with men- tal retardation and behavioral disor- ders (n = 106), and with mental retar- dation and severe physical handicap (n = 119)-and by 4 age groups-3-12 years, 13-20 years, 21-40 years, and 41+ years.

The behavioral group classifica- tion utilized in this study is a modifi- cation of the 1983 American Association of Mental Deficiency (AAMD) classification and terminol- ogy.l4 The Ministry of Labor and Welfare in Israel is using these modi- fied definitions and criteria with regard to placement of their clients.

Definitions and criteria for the four mental retardation groups

[placed in ordinal classification from least to greatest behavioral impair- ment] were as follows:

Educable: A population defined as independent in some everyday activities and in need of limited guidance and training for short periods of time in other daily activities.

Trainable: A population in need of some support in everyday activi- ties. This is constant support, not limited in time, that assists the individual in an active manner to achieve his/her needs in these activities.

With mental retardation and severe physical handicap (MR and SPH): A population in need of on-going support in all daily activities in order to satisfy those needs.

With mental retardation and behavioral problems (MR and BP): A population acting in a manner which can be destructive to an individual or/and the surround-

SCD Special Care in Dentistry, Vol 18 No 4 1998 151

Table 4. Ageadjusted means of DMF-T by clinic status*.

D-T M-T F-T DMF-T - - Clinic C f S D x k S D x c S D Fk SD

-

Yes 5.17 f 4.91 9.45 k 9.68 1.41 f 2.80 16.04 k 9.16

No 5.06 f 4.47 4.16 * 7.35 0.52 c 1.75 9.74 L 8.15

Total 5.12 L 4.68 6.71 f 8.94 0.95 k 2.36 12.79 ? 9.19 ~ ~ _ _ _ _ _ _ ~ ~

ANCOVA p < 0.05 p < 0.05 p < 0.001 p < 0.001

* N=385.

ings including property. This pop- ulation, therefore, is in need of on- going surveillance.

Prior to any examinations, a letter was sent to all residential settings involved in order to receive both site and guardian permission. A study in Israel which involves only an exami- nation and treatment plan does not necessitate a review and endorse- ment by a Human Subjects Committee.

Examinations were performed with subjects seated in stationary dental chairs in those institutions having a dental clinic. Where no den- tal equipment existed, a mobile chair and mobile dental lamp were uti- lized. Those suffering from mental retardation with severe physical handicap were examined in their wheelchair or in their mobile bed. In order to attempt examination of those who refused to cooperate, a team

which included the dentists, the assistant, the direct-care staff person, and two male assistants helped in performing the examination.

A World Health Organization (WHO) oral health survey form15 was modified and then utilized to record data. All examinations were per- formed with a dental explorer, a WHO probe, a dental mirror, and, whenever needed, Molt Mouth Gags for mouth stabilization to improve access and visibility.

The examination included an extensive intra-oral soft tissue evalu- ation, recording of DMF-T, and, final- ly, gingival and periodontal assess- ment by the gingival index (GI) and Community Periodontal Index of Treatment Needs (CPITN) as pub- lished by the WHO.15 In addition, all treatment needs were recorded. Radiographs were not used for caries detection.

Two calibrated experienced den-

tists conducted all of the examina- tions in various locations around the country. Calibration included a theo- retical overview discussing issues and questions which may be encoun- tered during the examination period. Subsequently, 50 non-MR patients were examined by both examiners to improve inter- and intra-examiner agreement. These replicate exams generated discussion and classifica- tions on diagnostic criteria contribut- ing to improved reliability and valid- ity; no specific percent agreement data were collected.

Means and standard deviations were calculated following age adjust- ments for all the groups for the DMF rates, restorative needs, and CPITN. ANCOVA and logistic regression analyses were utilized to determine differences within groups.

Results The educable group had the highest mean DMF-T value (17.52). This figure was statistically higher than those in all other behavior groups (p < 0.001). Those who suffered from mental retardation and severe physi- cal handicap (MR and SPH) had the lowest DMF-T rate (10.94). The high- est missing value (M-T) was also in the educable group (10.70) and sub- stantially higher than in all other groups. No significant differences were noted within the Filled (F-T) or Decay (D-T) components (Table 1).

Table 5. Percentage of persons having decayed, missing, and/or filled teeth by behavior groups.

Decayed, Missing, Decayed Teeth Missing Teeth Filled Teeth or Filled Teeth

Patient Category N % Yo % %

Educable 70 84

Trainable 92 84

MR & SPH 119 80

MR & BP 106 82

91

67

55 50

44

32

18

20

100

96

91 88

Total 387 82 63 27 93

Logistic regression* NS p < 0.01 p < 0.01 NS * Logistic regression with patient category and age as independent variables.

1S2 SCD Special Care in Dentistry, Vol18 No 4 1998

Table 6. Percentage of persons with specific dental care treatment needs by behavior groups.

Fissure Sealants Restorations Crowns/Pontics Root Canal Fillings Extraction

Patient Category N Yo Yo % Yo '%I

Educable 70 9 80 10 4 26

Trainable 92 23 78 8 2 24

MR & SPH 119 19 70 12 3 24

MR & BP 106 34 74 11 2 21

Total 387 22 75 10 3 24

Logistic regression* NS NS NS NS NS * Logistic regression with patient category and age as independent variables.

Table 2 presents the age-adjusted means for dental care treatment needs for the four behavior groups. No significant differences were found for restorations, crowns and pontics, root canal fillings, and extractions. However, a significant difference at a level of p < 0.05 was found for fissure sealant treatment with the lowest mean score in the MR and SPH group (0.87). An average of 1.16 teeth per individual was in need of sealants, 3.32 teeth needed restorations, 0.22 teeth required crowns, 0.03 teeth were determined to need root canal fillings, and 0.61 teeth were recommended for extraction.

A look at treatment needs by age (Table 3) confirmed the likely finding that more teeth were in need of fis- sure sealants in the youngest age groups-3.56 at age 3-12. Those aged 41+ were less likely to require restorations than all other groups (2.39 us. 3.87 for those 21-40). Older age groups were also in need of more extractions, root canal fillings, and pontics. Ages 3-12 needed more crowns than other age groups (e.g., stainless steel crowns).

An evaluation of the DMF-T rate by existence of a dental clinic at the examined institution (Table 4) revealed that those having clinics had a much higher DMF-T (16.04 us. 9.74; p < 0.001). Statistically different high- er scores were also found in all DMF index components (D-T 5.17 us. 5.06, M-T 9.45 us. 4.16, and F-T 1.41 us. 0.52).

The percentage of persons affected by having any decayed, missing, and/or filled teeth by behavior group

is represented in Table 5. Eighty-two percent of the total population had decay, 63% had missing teeth, and only 27% had restorations. The edu- cable group had the highest percent- age of restorations (44?0), in compari- son with only 18% among the MR and SPH group (p < 0.01). Ninety-one percent of the educable group had at least one missing tooth, as compared with only 50% among the MR and BP groups (p < 0.01).

need of specific non-periodontal den- tal care treatment did not significant- ly differ between behavior groups (Table 6). In the total population, 75% were in need of restorations, 3% in need of root canal fillings, and 24% in need of extractions.

means for periodontal treatment needs of those 13 years of age and older. The most significant difference was found between the MR and SPH groups at CPITN = 3 (pockets 4-5 mm), presenting the highest need score (Z = 2.93), and the educable group the lowest (X = 1.89). Among those having no teeth in the sextant, the educable had the highest score (K = 2.48), in comparison with only X = 1.28 among the MR and BP groups.

Table 8 indicates the percentage of people aged 13 and older affected by periodontal problems, as indicated by the CPITN. Bleeding only was found in 11% of the participants, cal- culus among 3870, pockets of 4-5 mm among 75"/0, with no significant dif- ferences between groups. Forty-four percent had pockets 2 6 mm among

The percentage of participants in

Table 7 presents the age-adjusted

the MR and SPH groups, as com- pared with only 21% among the edu- cable group (p < 0.05).

Discussion The mean age of the trainable group was 30.45 15.28 years, that of the educable group was 37.72 k 12.07 years, and that of the other groups approximately 27 years. These sub- stantial mean age differences promp- ted analyses utilizing age adjustment methodology. We found the MR behavioral impairment scale utilized by the government for client place- ment to have fairly well-defined boundaries and a reasonable ordinal classification system for this study. The accuracy of the findings from the clinical examination for the MR and BP groups was slightly lower due to variance in patient cooperation.

The total DMF-T in this study (12.78) was lower than those in sever- al other studies previously cited, yet more similar when compared with the DMF-T score of the educable group (17.52). For example, Holland and O'Mullane, in Ireland,6 reported a mean DMF-T of 19.1 in the 21-50 age group. These various DMF-T findings may be partially explained by differing ages and mental retarda- tion levels of the study participants, variable treatment interventions, and study protocol characteristics.

Unrestored dental caries was quite prevalent. The total sample had an age-adjusted D-T mean of 5.09, and 82% of the total study population had at least one carious tooth. These find-

SCD Special Care in Dentistry, Vol18 No 4 1998 153

Table 7. Age-adjusted means for periodontal treatment needs (CPITN) by behavior groups (age 13 or older).

CPITN = 0 CPITN = 1 CPITN = 2 CPITN = 3 CPITN = 4 CPITN = 5

Oral Hygiene Bleeding Calculus Pockets = 4.5 Pockets = 6 No Teeth ~ ~ ~ - - ~ Behavior Group N X X X X X X

Educable 70 0.28 0.22 0.67 1.89 0.28 2.48

Trainable 81 0.22 0.12 1.05 2.34 0.64 1.45

MR & SPH 102 0.07 0.07 0.61 2.93 0.85 1.32

MR & BP 88 0.22 0.15 0.50 2.66 0.60 1.28

Total 341 0.19 0.13 0.70 2.51 0.62 1.58 ~ ~~

ANCOVA p = 0.05 NS p < 0.05" p < 0.001b p < 0.05c p < 0.001d a Significant difference between the trainable and the MR & BP groups (ANCOVA with Bonferroni correction), p < 0.02.

Significant difference between the educable group and the MR & SPH and MR & BP groups, as well as between the MR & SPH and MR & BP groups (ANCOVA with Bonferroni correction), p < 0.02. Significant difference between the educable and the MR & SPH groups (ANCOVA with Bonferroni correction), p < 0.03. The difference between the MR & SPH and the trainable groups was not significant. All other combinations between 2 groups were statistically significant (ANCOVA with Bonferroni correction), p < 0.001.

ings alone should prompt more effec- tive prevention efforts and treatment opportunities for individuals with mental retardation.

The behavioral groups were remarkably similar, with active caries scores ranging from X = 4.65 teeth in the MR and SPH groups to X = 5.64 teeth in the trainable group. This was a surprising finding due to the pre- sumption that risk factors associated with level of mental retardation im- pairment (e.g., less dietary supervision in the higher-functioning groups us. poorer oral hygiene capabilities in the lower-functioning groups) could pre- dispose to higher caries rates.

An analysis of the data from this study showed that mental retardation behavioral status had a significant impact upon certain aspects of oral health status. The educable partici- pants differed most from the other groups with the highest total DMF-T and M-T scores, as well as having at least one missing tooth. Several char- acteristics of the educable participants may have contributed to these find- ings: (1) They may be more likely to perceive a need for on-going dental care; (2) they may be more capable of reporting dental symptoms; (3) they may have readier access to communi- ty-based dental services; and (4)

when at the dental clinic, they may receive a preferred extraction approach to dental caries compared with restorations.

Consistent with other studies,3r5 restorations were quite rare in all Israeli behavioral MR groups, with only 27% of the total sample having at least one restored tooth, and the low F-T mean scores ranged from 0.66 to 1.51. Although age-adjusted mean F-T scores were not significant- ly different between behavior groups, the educable group did have signifi- cantly higher numbers of individuals who had at least one restoration. These findings suggest that dentists are restoring some caries, particularly in the less-impaired individuals, but are again predisposed to extract most carious teeth.

An evaluation of the DMF-T score by existence of a dental clinic at an institution revealed that these resi- dents had much higher mean DMF-T component and total scores than resi- dents at other facilities without den- tal clinics (p < 0.05). The DMF-T, F-T, and perhaps even the M-T scores were not particularly surprising, given the greater likelihood of receiv- ing dental care on site, yet the higher D-T rate was an unanticipated find- ing, suggesting that residents at insti-

tutions with dental facilities may have other caries risk factors.

study were in need of specific dental care. These substantial unmet dental needs should prompt efforts by the dental profession and those responsi- ble for facilitating health care for individuals with MR to seek better solutions to increase access to dental services.

Periodontal conditions of individ- uals with mental retardation have been previously investigated.16-21 This study reinforces and adds some new information pertaining to differ- ences in severity and prevalence of disease by behavior group. Perio- dontal treatment needs indicated that the behavioral groups less likely to utilize dental services (MR & SPH and MR & BP groups) had more severe periodontal problems. Explanatory risk factors may include poorer oral hygiene, mouth dryness associated with prescribed medica- tions, and less frequent and effective periodontal maintenance therapies.

An analysis of our findings sug- gests that there is a significant need to train dentists in the management of individuals with MR at various behavioral impairment levels. We believe that a highly experienced and

A great many participants in the

154 SCD Special Care in Dentistry, Vol 18 No 4 1998

Table 8. Percentage of persons represented in CPITN categories by behavior groups (age 13+).

CPITN = 1 CPITN = 2 CPITN = 3 CPITN = 4

Bleeding Calculus Pockets = 4,s Pockets = 6

Patient Category N YO Yo Y O YO ~ ~~ ~

Educable 70

Trainable 81

MR & SPH 102

MR & BP 88

All Patients 341

~

14

9

8

14

11

30

47

35

38

38

64

73

81

80

75

21

32

44

27

32

Logistic Regression NS NS NS p < 0.05

qualified dentist/hygienist who understands the problems of this spe- cial population can substantially improve dental treatment outcomes. Dental providers should develop pri- ority-based treatment plans and be encouraged to utilize more effective restorative and periodontal therapies. Institutions for MR individuals should be equipped with all the nec- essary dental equipment. Patients needing treatment under general anesthesia or IV sedation should be referred to appropriate treatment centers. The rationale and protocol for the appropriate use of restraints and chemosedation should be under- stood.

Greater emphasis needs to be placed upon the importance of main- taining the natural dentition in MR populations for as long as possible. Primary prevention approaches should be taught to staff employed within institutions, to caregivers, and, when appropriate, to the indi- vidual patient. Although patient age, behavior classification, and existence of a dental clinic may substantially influence the dental status, all deserve quality dental care.

Dr. Shapira is Associate Professor and Dr. Efrat an Instructor in the Department of Pediatric Dentistry, and Dr. Mann is Associate Professor and Chair, Department of Community Dentistry, all at The Hebrew University- Hadassah School of Dental Medicine, PO Box 12272, Jerusalem, Israel 91120. Dr. Berkey is Associate Professor and Chair, Department of

Applied Dentistry, University of Colorado School of Dentistry. Correspondence should be addressed to Dr. Shapira.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Tesini DA. Age, degree of mental retarda- tion, institutionalization and socioeco- nomic status of mentally retarded indi- viduals. Community Dent Oral Epidemiol 8:355-9,1980. Butts JE. Dental status of mentally retard- ed children. A survey of the prevalence of certain dental conditions in mentally retarded children in Georgia. J Public Health Dent 27195-211,1967. Nowak AJ. Dental disease in handicapped persons. Spec Care Dent 4:66-9,1984. Forsberg H, Quick-Nilsson I, Gustavson KH, Jagell S. Dental health and dental care in severely mentally retarded chil- dren. Swed Dent J 9:15-28,1985. Pieper K, Dirks B, Kessler P. Caries, oral hygiene and periodontal disease in handi- capped adults. Community Dent Oral Epidemiol14:28-30,1986. Holland TJ, O’Mullane DM. Dental treat- ment needs in three institutions for the handicapped. Community Dent Oral Epidemiol14:73-5,1986. Gabre P, Gahnberg L. Dental health status of mentally retarded adults with various living arrangements. Spec Care Dent 14:203-7,1994. Tesini DH. An annotated review of the lit- erature of dental caries and periodontal disease in mentally retarded individuals. Spec Care Dent 1:75-87,1981. Haavio ML. Oral health care of the men- tally retarded and other persons with dis- abilities in the Nordic countries: Present situation and plans for the future. Spec Care Dent 15:65-9,1995. Stabholz A, Mann J, Sela M, Schurr D, Steinberg D, Dori S, et al. Caries experi- ence, periodontal treatment needs, sali- vary pH and Streptococcus mutans counts in a Down’s Syndrome population. Spec Care Dent 11203-8,1991.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

Shapira J, Stabholz A, Schurr D, Sela M, Mann J. Caries levels, Streptococcus nlutnns counts, salivary pH and periodontal needs of adult Down’s Syndrome patients. Spec Care Dent 11:248-51,1991. Schwartz E, Vigild M. Provision of dental services for handicapped children in Denmark. Community Dent Health 4:35- 42, 1987. Hinchliffe JE, Fairpo CG, Curzon MEJ. The dental condition of mentally handi- capped adults attending adult training centers in Hull. Community Dent Health 5:151-62, 1988. Grossman HJ. Classification in mental retardation-American Association of Mental Deficiency. 1983 revision. AAMD Publication. World Health Organization. Oral health surveys. Basic methods. 3rd ed. Geneva: World Health Organization, 1987. Saxen L, Aula S. Periodontal bone loss in patients with Down’s Syndrome: A fol- low-up study. J Periodontol53:158-62, 1982. Barnett ML, Press KP, Friedman D, Sonnenberg EM. The prevalence of peri- odontitis and dental caries in a Down’s Syndrome population. J Periodontol

Vyas HA, Damle SG. Comparative study of oral health status of mentally subnor- mal, physically handicapped, juvenile delinquents and normal children of Bombay. J Indian SOC Pedodont Prev Dent

Swallow JN. Dental disease in children with Down’s Syndrome. J Ment Defic Res

Kroll RG, Budnick J, Kobren A. Incidence of dental caries and periodontal disease in Down’s Syndrome. NY State Dent J 36:151-6,1970. Ulseth JO, Hestnes A, Stovner LJ, Storhaug K. Dental caries and periodonti- tis in persons with Down’s Syndrome. Spec Care Dent 11:71-3,1991.

57288-93,1986.

9(1):13-6,1991.

8:102-18,1964.

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Table 8. Percentage of persons represented in CPITN categories by behavior groups (age 13+).

CPITN = 1 CPITN = 2 CPITN = 3 CPITN = 4

Bleeding Calculus Pockets = 4 3 Pockets = 6

Patient Category N % Yo % Yo ~~~~ ~ ~

Educable 70 14 30 64 21

Trainable 81 9 47 73 32

MR & SPH 102 8 35 81 44

MR & BP 88 14 38 80 27

All Patients 341 11 38 75 32

Logistic Regression NS NS NS p < 0.05

qualified dentist/hygienist who understands the problems of this sye- cia1 population can substantially improve dental treatment outcomes. Dental providers should develop pri- ority-based treatment plans and be encouraged to utilize more effective restorative and periodontal therapies. Institutions for MR individuals should be equipped with all the nec- essary dental equipment. Patients needing treatment under general anesthesia or IV sedation should be referred to appropriate treatment centers. The rationale and protocol for the appropriate use of restraints and chemosedation should be under- stood.

Greater emphasis needs to be placed upon the importance of main- taining the natural dentition in MR populations for as long as possible. Primary prevention approaches should be taught to staff employed within institutions, to caregivers, and, when appropriate, to the indi- vidual patient. Although patient age, behavior classification, and existence of a dental clinic may substantially influence the dental status, all deserve quality dental care.

Dr. Shapira is Associate Professor and Dr. Efrat an Instructor in the Department of Pediatric Dentistry, and Dr. Mann is Associate Professor and Chair, Department of Community Dentistry, all at The Hebrew University- Hadassah School of Dental Medicine, PO Box 12272, Jerusalem, Israel 91120. Dr. Berkey is Associate Professor and Chair, Department of

Applied Dentistry, University of Colorado School of Dentistry. Correspondence should be addressed to Dr. Shapira.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Tesini DA. Age, degree of mental retarda- tion, institutionalization and socioeco- nomic status of mentally retarded indi- viduals. Community Dent Oral Epidemiol 8:355-9, 1980. Butts JE. Dental status of mentally retard- ed children. A survey of the prevalence of certain dental conditions in mentally retarded children in Georgia. J Public Health Dent 27195-211,1967. Nowak AJ. Dental disease in handicapped persons. Spec Care Dent 4:66-9,1984. Forsberg H, Quick-Nilsson I, Gustavson KH, Jagell S. Dental health and dental care in severely mentally retarded chil- dren. Swed Dent J 9:15-28,1985. Pieper K, Dirks B, Kessler P. Caries, oral hygiene and periodontal disease in handi- capped adults. Community Dent Oral Epidemiol14:ZB-30,1986. Holland TJ, O’Mullane DM. Dental treat- ment needs in three institutions for the handicapped. Community Dent Oral Epidemiol14:73-5,1986. Gabre P, Gahnberg L. Dental health status of mentally retarded adults with various living arrangements. Spec Care Dent

Tesini DH. An annotated review of the lit- erature of dental caries and periodontal disease in mentally retarded individuals. Spec Care Dent 1:75-87,1981. Haavio ML. Oral health care of the men- tally retarded and other persons with dis- abilities in the Nordic countries: Present situation and plans for the future. Spec Care Dent 15:65-9,1995. Stabholz A, Mann J, Sela M, Schurr D, Steinberg D, Dori S, et al. Caries experi- ence, periodontal treatment needs, sali- vary pH and Streptococcus mutans counts in a Down’s Syndrome population. Spec Care Dent 11:203-8,1991.

14:203-7,1994.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

Shapira J, Stabholz A, Schurr D, Sela M, Mann J. Caries levels, Streptococcus nlutans counts, salivary pH and periodontal needs of adult Down’s Syndrome patients. Spec Care Dent 11:248-51,1991. Schwartz E, Vigild M. Provision of dental services for handicapped children in Denmark. Community Dent Health 435- 42, 1987. Hinchliffe JE, Fairpo CG, Curzon MEJ. The dental condition of mentally handi- capped adults attending adult training centers in Hull. Community Dent Health

Grossman HJ. Classification in mental retardation-American Association of Mental Deficiency. 1983 revision. AAMD Publication. World Health Organization. Oral health surveys. Basic methods. 3rd ed. Geneva: World Health Organization, 1987. Saxen L, Aula S. Periodontal bone loss in patients with Down’s Syndrome: A fol- low-up study. J Periodontol53:158-62, 1982. Barnett ML, Press KP, Friedman D, Sonnenberg EM. The prevalence of peri- odontitis and dental caries in a Down‘s Syndrome population. J Periodontol

Vyas HA, Damle SG. Comparative study of oral health status of mentally subnor- mal, physically handicapped, juvenile delinquents and normal children of Bombay. J Indian Soc Pedodont Prev Dent

Swallow JN. Dental disease in children with Down’s Syndrome. J Ment Defic Res

Kroll RG, Budnick J, Kobren A. Incidence of dental caries and periodontal disease in Down’s Syndrome. NY State Dent J

Ulseth JO, Hestnes A, Stovner LJ, Storhaug K. Dental caries and periodonti- tis in persons with Down’s Syndrome. Spec Care Dent 11:71-3,1991.

5:151-62, 1988.

57288-93,1986.

9(1):13-6,1991.

8:102-18,1964.

36:151-6,1970.

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