U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES l NATIONAL INSTITUTES OF HEALTH l National Institute of Dental and Craniofacial Research

Providing oral care to people with mental retardation requiresadaptation of the skills you use every day. In fact, most peoplewith mild or moderate mental retardation can be treatedsuccessfully in the general practice setting. This booklet will help you

make a difference in the lives of people who need professional oral care.

Mental retardation is a disorder of intellectual and adaptive

functioning, meaning that people who are affected are challenged

by the skills they use in everyday life. Mental retardation is not a

disease or a mental illness; it is a

developmental disability that varies

in severity and is usually associated

with physical problems. While one

person with mental retardation may

have slight difficulty thinking and

communicating, another may face

major challenges with basic self-care

and physical mobility.

Practical Oral Care for People With Mental Retardation

CONTENTSHEALTH CHALLENGES INMENTAL RETARDATIONAND STRATEGIES FORCARE

2 . . . . . . . . . . . . . . . . . . . . .

Mental challenges3 . . . . . . . . . . . . . . . . . . . . .

Behavior challenges4 . . . . . . . . . . . . . . . . . . . . .

Physical challenges

Cerebral palsy

Cardiovascular anomalies5 . . . . . . . . . . . . . . . . . . . . .

Seizures

Visual impairments

Hearing loss and deafness

ORAL HEALTHPROBLEMS IN MENTALRETARDATION ANDSTRATEGIES FOR CARE

6 . . . . . . . . . . . . . . . . . . . . .

Periodontal disease

Dental caries

Malocclusion 7 . . . . . . . . . . . . . . . . . . . . .

Missing permanent teeth,delayed eruption, andenamel hypoplasia

Damaging oral habits

Trauma and injury

ADDITIONAL READINGS

Data indicate thatpeople with mentalretardation have moreuntreated caries and ahigher prevalence ofgingivitis and otherperiodontal diseasesthan the generalpopulation.

Many people with mental retardation alsohave other disabilities such as cerebral palsy,seizure or psychiatric disorders, attentiondeficit/hyperactivity disorder, or problemswith vision, communication, and eating.Though language and communicationproblems are common in anyone withmental retardation, motor skills are typi-cally more affected when a person hascoexisting conditions.

Before the appointment, obtain and reviewthe patients medical history. Consultationwith physicians, family, and caregivers isessential to assembling an accurate medicalhistory. Also, determine who can legallyprovide informed consent for treatment.

MENTAL CHALLENGES. People withmental retardation learn slowly and oftenwith difficulty. Ordinary activities of dailyliving, such as brushing teeth and gettingdressed, and understanding the behavior ofothers as well as their own, can all presentchallenges to a person with mentalretardation.

Set the stage for a successful visit byinvolving the entire dental teamfromthe receptionists friendly greeting to thecaring attitude of the dental assistant inthe operatory. All should be aware ofyour patients mental challenges.

Reduce distractions in the operatory,such as unnecessary sights, sounds, orother stimuli, to compensate for theshort attention spans commonlyobserved in people with mentalretardation.

Talk with the parent or caregiver todetermine your patients intellectualand functional abilities, then explaineach procedure at a level the patientcan understand. Allow extra time toexplain oral health issues or instructionsand demonstrate the instruments youwill use.

Address your patient directly and withrespect to establish a rapport. Even ifthe caregiver is in the room, direct allquestions and comments to yourpatient.

Use simple, concrete instructions andrepeat them often to compensate for anyshort-term memory problems. Speakslowly and give only one direction at atime.

Be consistent in all aspects of oral care,since long-term memory is usually unaf-fected. Use the same staff and dentaloperatory each time to help sustainfamiliarity. The more consistency youprovide for your patients, the morelikely they will cooperate.

Listen actively, since communicatingclearly is often difficult for people withmental retardation. Show your patientwhether you understand. Be sensitive tothe methods he or she uses to communi-cate, including gestures and verbal ornonverbal requests.

2

Health Challenges in MentalRetardation and Strategies for Care

MENTAL RETARDATIONBEHAVIOR CHALLENGES. While mostpeople with mental retardation do not posesignificant behavior problems that compli-cate oral care, anxiety about dental treat-ment occurs frequently. People unfamiliarwith a dental office and its equipment andinstruments may exhibit fear. Some reactto fear with uncooperative behavior, suchas crying, wiggling, kicking, aggressivelanguage, or anything that will help themavoid treatment. You can make oral healthcare a better experience by comforting yourpatients and acknowledging their anxiety.

Talk to the caregiver or physician abouttechniques they have found to be effec-tive in managing the patients behavior.

Schedule patients with mental retarda-tion early in the day if possible. Earlyappointments can help ensure thateveryone is alert and attentive andthat waiting time is reduced.

Keep appointments short and postponedifficult procedures until after yourpatient is familiar with you and yourstaff.

Allow extra time for your patients to getcomfortable with you, your office, andthe entire oral health care team. Invitepatients and their families to visit youroffice before beginning treatment.

Permit the parents or caregiver to comeinto the treatment setting to providefamiliarity, help with communication,and offer a calming influence by holdingyour patients hand during treatment.Some patients behavior may improveif they bring comfort items such as astuffed animal or blanket.

Reward cooperative behavior with com-pliments throughout the appointment.

Consider nitrous oxide/oxygen sedationto reduce anxiety and fear and improvecooperation. Obtain informed consentfrom the legal guardian before admin-istering any kind of sedation.

Use immobilization techniques onlywhen absolutely necessary to protectthe patient and staff during dental treat-mentnot as a convenience. There areno universal guidelines on immobiliza-tion that apply to all treatment settings.Before employing any kind of immobi-lization, it may help to consult availableguidelines on federally funded care,your State department of mental retar-dation/mental health, and your StateDental Practice Act. Guidelines onbehavior management published bythe American Academy of PediatricDentistry (www.aapd.org) may alsobe useful. Obtain consent from yourpatients legal guardian and choosethe least restrictive technique thatwill allow you to provide care safely.Immobilization should not causephysical injury or undue discomfort.

People with mental retardation oftenengage in perseveration, a continuous,meaningless repetition of words, phrases,or movements. Your patient may mimicthe sound of the suction, for example,or repeat an instruction over and again.Avoid demonstrating dental equipment ifit triggers perseveration, and note this inthe patients record.

3

Allow extra time

for your patient

to get comfortable

with you, your

office, and the

entire oral health

care team.

PHYSICAL CHALLENGES. Mental retardation does not always include aspecific physical trait, although manypeople have distinguishing features such asorofacial abnormalities, scoliosis, unsteadygait, or hypotonia due to coexisting con-ditions. Countering physical challengesrequires attention to detail.

Maintain clear paths for movementthroughout the treatment setting. Keepinstruments and equipment out of thepatients way.

Place and maintain your patient in thecenter of the dental chair to minimizethe risk of injury. Placing pillows onboth sides of the patient can providestability.

If you need to transfer your patientfrom a wheelchair to the dental chair,ask the patient or caregiver about specialpreferences such as padding, pillows, orother things you can provide to ease thetransition. The patient or caregiver canoften explain how to make a smoothtransfer. (See Wheelchair Transfer: AHealth Care Providers Guide, also partof this series.)

Some patients cannot be moved intothe dental chair but instead must betreated in their wheelchairs. Somewheelchairs recline or are speciallymolded to fit peoples bodies. Lockthe wheels, then slip a sliding board(also called a transfer board) behindthe patients back to provide supportfor the head and neck during care.

CEREBRAL PALSY occurs in one-fourthof those who have mental retardationand tends to affect motor skills more thancognitive skills. Uncontrolled body move-ments and reflexes associated with cerebralpalsy can make it difficult to provide care.

Place and maintain your patient in thecenter of the dental chair. Do not forcearms and legs into unnatural positions,but allow your patient to settle into aposition that is comfortable and willnot interfere with dental treatment.

Observe your patients movements andlook for patterns to help you anticipatedirection and intensity. Trying to stopthese movements may only intensify theinvoluntary response. Try instead toanticipate the movements, blendingyour movements with those of yourpatient or working around them.

Softly cradle your patients head duringtreatment. Be gentle and slow if youneed to turn the patients head.

Help minimize the gag reflex by placingyour patients chin in a neutral or down-ward position.

Stay alert and work efficiently in shortappointments.

Exert gentle but firm pressure on yourpatients arm or leg if it begins to shake.

Take frequent breaks or consider pre-scribing muscle relaxants when longprocedures are needed. People withcerebral palsy may need sedation, gen-eral anesthesia, or hospitalization ifextensive dental treatment is required.

CARDIOVASCULAR ANOMALIESsuch as heart murmurs and damaged heartvalves occur frequently in people withmental retardation, especially those withDown syndrome or multiple disabilities.To avoid complications, consult thepatients physician and use the AmericanHeart Associations antibiotic prophylacticregimen (www.americanheart.org) for dentaltreatment when indicated.

4

MENTAL RETARDATIONSEIZURES are common in this populationbut can usually be controlled with anti-convulsant medications. The mouth isalways at risk during a seizure: Patientsmay chip teeth or bite the tongue orcheeks. Persons with controlled seizure disorders can easily be treated in thegeneral dental office.

Consult your patients physician.Record information in the chart aboutthe frequency of seizures and themedications used to control them.Determine before the appointmentwhether medications have been taken asdirected. Know and avoid any factorsthat trigger your patients seizures.

Be prepared to manage a seizure. Ifone occurs during oral care, removeany instruments from the mouth andclear the area around the dental chair.Attaching dental floss to rubber damclamps and mouth props when treat-ment begins can help you remove themquickly. Do not attempt to insert anyobjects between the teeth during aseizure.

Stay with your patient, turn him or herto one side, and monitor the airway toreduce the risk of aspiration.

VISUAL IMPAIRMENTS, most commonlystrabismus (crossed or misaligned eyes) andrefractive errors, can be managed with care-ful planning.

Determine the level of assistance yourpatient requires to move safely throughthe dental office.

Use your patients other senses to con-nect with them, establish trust, andmake treatment a good experience.Tactile feedback, such as a warm hand-shake, can make your patients feelcomfortable.

Face your patients when you speak andkeep them apprised of each upcomingstep, especially when water will be used.Rely on clear, descriptive language toexplain procedures and demonstratehow equipment might feel and sound.Provide written instructions in largeprint (16 point or larger).

HEARING LOSS and DEAFNESS canalso be accommodated with careful plan-ning. Patients with a hearing problem mayappear to be stubborn because of theirseeming lack of response to a request.

Patients may want to adjust theirhearing aids or turn them off, sincethe sound of some instruments maycause auditory discomfort.

If your patient reads lips, speak in anormal cadence and tone. If yourpatient uses a form of sign language,ask the interpreter to come to theappointment. Speak with this personin advance to discuss dental terms andyour patients needs.

Visual feedback is helpful. Maintaineye contact with your patient. Beforetalking, eliminate background noise(turn off the radio and the suction).Sometimes people with a hearing losssimply need you to speak clearly in aslightly louder voice than normal.Remember to remove your facemaskfirst or wear a clear face shield.

5

Record in the patients chart

strategies that were successful in

providing care. Note your patients

preferences and other unique details

that will facilitate treatment, such as

music, comfort items, and flavor

choices.

In general, people with mental retardationhave poorer oral health and oral hygienethan those without this developmental dis-ability. Data indicate that people who havemental retardation have more untreatedcaries and a higher prevalence of gingivitisand other periodontal diseases than thegeneral population.

PERIODONTAL DISEASE. Medications,malocclusion, multiple disabilities, andpoor oral hygiene combine to increase therisk of periodontal disease in people withmental retardation.

Encourage independence in daily oralhygiene. Ask patients to show you howthey brush, and follow up with specificrecommendations on brushing methodsor toothbrush adaptations. Involve yourpatients in hands-on demonstrations ofbrushing and flossing.

Some patients cannot brush and flossindependently due to impaired physicalcoordination or cognitive skills. Talkto their caregivers about daily oralhygiene. Do not assume that all care-givers know the basics; demonstrateproper brushing and flossing techniques.A power toothbrush or a floss holdercan simplify oral care. Also, use yourexperiences with each patient to demon-strate sitting or standing positions forthe caregiver. Emphasize that a consis-tent approach to oral hygiene is impor-tantcaregivers should try to use thesame location, timing, and positioning.

Some patients benefit from the dailyuse of an antimicrobial agent such aschlorhexidine. Recommend an appro-

priate delivery method based on yourpatients abilities. Rinsing, for example,may not work for a patient who hasswallowing difficulties or one who can-not expectorate. Chlorhexidine appliedusing a spray bottle or toothbrush isequally efficacious.

If use of particular medications has ledto gingival hyperplasia, emphasize theimportance of daily oral hygiene andfrequent professional cleanings.

DENTAL CARIES. People with mentalretardation develop caries at the samerate as the general population. The prevalence of untreated dental caries, however, is higher among people with mental retardation, particularly those living in noninstitutional settings.

Emphasize noncariogenic foods andbeverages as snacks. Advise caregiversto avoid using sweets as incentives orrewards.

Advise patients taking medicines thatcause xerostomia to drink water often.Suggest sugar-free medicine if availableand stress the importance of rinsingwith water after dosing.

Recommend preventive measures suchas fluorides and sealants.

MALOCCLUSION. The prevalence ofmalocclusion in people with mental retarda-tion is similar to that found in the generalpopulation, except for those with coexistingdisabilities such as cerebral palsy or Downsyndrome. A developmental disability inand of itself should not be perceived as abarrier to orthodontic treatment. The abil-ity of the patient or caregiver to maintaingood daily oral hygiene is critical to thefeasibility and success of treatment.

6

Oral Health Problems in MentalRetardation and Strategies for Care

A developmental

disability in and

of itself should

not be perceived

as a barrier to

orthodontic

treatment.

TIPS FOR CAREGIVERS ARE AVAILABLE IN THE BOOKLETDENTAL CARE EVERY DAY: A CAREGIVERS GUIDE, ALSO PART OF THIS SERIES.

MENTAL RETARDATIONMISSING PERMANENT TEETH, DELAYEDERUPTION, and ENAMEL HYPOPLASIA aremore common in people with mental retardationand coexisting conditions than in people withmental retardation alone.

Examine a child by his or her first birthday andregularly thereafter to help identify unusual toothformation and patterns of eruption.

Consider using a panoramic radiograph to deter-mine whether teeth are congenitally missing.Patients often find this technique less threateningthan individual films.

Take appropriate steps to reduce sensitivity andrisk of caries in your patients with enamelhypoplasia.

DAMAGING ORAL HABITS are a problem forsome people with mental retardation. Commonhabits include bruxism; mouth breathing; tonguethrusting; self-injurious behavior such as pickingat the gingiva or biting the lips; and pica, eatingobjects and substances such as gravel, cigarettebutts, or pens. If a mouth guard can be tolerated,prescribe one for patients who have problems withself-injurious behavior or bruxism.

TRAUMA and INJURY to the mouth from falls oraccidents occur in people with mental retardation.Suggest a tooth-saving kit for group homes.Emphasize to caregivers that traumas require imme-diate professional attention and explain the proce-dures to follow if a permanent tooth is knocked out.Also, instruct caregivers to locate any missing piecesof a fractured tooth, and explain that radiographs ofthe patients chest may be necessary to determinewhether any fragments have been aspirated.

Physical abuse often presents as oral trauma. Abuseis reported more frequently in people with develop-mental disabilities than in the general population. Ifyou suspect that a child is being abused or neglected,State laws require that you call your Child ProtectiveServices agency. Assistance is also available from theChildhelp USA National Child Abuse Hotline at(800) 4224453 or the National Clearinghouse on

Child Abuse and Neglect Information(http://nccanch.acf.hhs.gov).

Making a difference in the oral health of aperson with mental retardation may go slowlyat first, but determination can bring positiveresultsand invaluable rewards. By adoptingthe strategies discussed in this booklet, youcan have a significant impact not only on yourpatients oral health, but on their quality oflife as well.

Additional ReadingsBatshaw ML, Shapiro BK. Mental retardation. InBatshaw ML. Children With Disabilities (5th ed.).Baltimore, MD: Paul H. Brookes Publishing Co.,2002. pp. 287305.

Horwitz SM, Kerker BD, Owens PL, Zigler E.Dental health among individuals with mental retar-dation. In The Health Status and Needs of IndividualsWith Mental Retardation. New Haven, CT: YaleUniversity School of Medicine, 2000. pp. 119134.

U.S. Public Health Service. Closing the Gap: ANational Blueprint for Improving the Health ofIndividuals With Mental Retardation. Report of theSurgeon Generals Conference on Health Disparitiesand Mental Retardation. Washington, DC, February2001.

Weddell JA, Sanders BJ, Jones JE. Dental problemsof children with disabilities. In McDonald RE, AveryDR. Dentistry for the Child and Adolescent (7th ed.).St. Louis, MO: Mosby, 2000. pp. 566599.

7

For more information about mental retardation, contact

National Institute of Child Health and HumanDevelopment Information Resource CenterP.O. Box 3006Rockville, MD 20847(800) 3702943www.nichd.nih.gov NICHDInformationResourceCenter@mail.nih.gov

This booklet is one in a series on providing oral care for peoplewith mild or moderate developmental disabilities. The issues andcare strategies listed are intended to provide general guidance onhow to manage various oral health challenges common in peoplewith mental retardation.

Other booklets in this series:

Continuing Education: Practical Oral Care for PeopleWith Developmental Disabilities

Practical Oral Care for People With Autism

Practical Oral Care for People With Cerebral Palsy

Practical Oral Care for People With Down Syndrome

Wheelchair Transfer: A Health Care Providers Guide

Dental Care Every Day: A Caregivers Guide

For additional copies of this booklet, contact

National Institute of Dental and Craniofacial ResearchNational Oral Health Information Clearinghouse1 NOHIC WayBethesda, MD 208923500(301) 4027364www.nidcr.nih.govnohic@nidcr.nih.gov

This publication is not copyrighted. Make as many photocopies as you need.

NIH Publication No. 045194Printed May 2004

ACKNOWLEDGMENTS

The National Institute of Dental and Craniofacial Researchthanks the oral health professionals and caregivers whocontributed their time and expertise to reviewing and pretesting the Practical Oral Care series.

Expert Review Panel Mae Chin, RDH, University of Washington, Seattle, WA

Sanford J. Fenton, DDS, University of Tennessee, Memphis, TN

Ray Lyons, DDS, New Mexico Department of Health, Los Lunas, NM

Christine Miller, RDH, University of the Pacific, San Francisco, CA

Steven P. Perlman, DDS, Special Olympics Special Smiles, Lynn, MA

David Tesini, DMD, Natick, MA

National Institute of Dentaland Craniofacial Research

Centers for Disease Controland Prevention

National Institute of Child Healthand Human Development

Special Care Dentistry