ISSN   0974-3618  (Print)                    www.rjptonline.org

            0974-360X (Online)

 

 

REVIEW ARTICLE

 

Management of oral care among people with intellectual disability

 

Sai Chaitanya Raj. B

Saveetha Dental College and Hospitals, Chennai

*Corresponding Author E-mail:

 

ABSTRACT:

Aim: To make a review on the needs and managements of oral care among a people with intellectual disability.

Objective: The objective of this study is to find out the various oral problems in a adults with intellectual disability and to review the ways of improving their dental health.

Background: Previous research has found an unmet need for oral care. The key factors which have been indicated are low expectations, fear of treatment, lack of awareness among carers and problems in accessing dental services.

The aims of the present study were:

(1) to assess the extent of unmet clinical needs in a group.

(2) to explore their perceptions of teeth and contact with dentists to identify how oral care can be improved.

Reason: Caretakers requested training in oral care and the use of dental services. Dental screening checks and oral care training for carers should be made easily available. Care plans should include tooth-brushing and dietary issues for all clients who have their own natural teeth.

 

KEY WORDS: Oral care, caretakers, tooth brushing, dental screening, natural teeth, intellectual disability.

 

 


INTRODUCTION:

Mental  retardation  (MR)  refers  to  subaverage  general  intellectual functioning  which  originates  during  the  development  period  and is associated  with  impairment  in  adaptive  behaviour.  General intellectual  functioning  means  the  results  obtained  by  administration of  standardized  general  intelligence  tests  for  the  purpose.  The significant subaverage  is  defined  as  I.Q.  of  70  or  below  on  the standardized  scale  of  intelligence.  The  adaptive  behaviour  is  defined as  the  degree  with  which  the  individual  meets  the  standards  of personal  independence  and  social  responsibility  in  relation  to  his age  and  cultural  environment  [1].

 

 

 

 

 

 

 

Received on 13.05.2015          Modified on 12.06.2015

Accepted on 05.07.2015        © RJPT All right reserved

Research J. Pharm. and Tech. 8(8): August, 2015; Page 1068-1072

DOI: 10.5958/0974-360X.2015.00184.5

 

People with intellectual disabilities require extreme care of both their physical and also their mental health. Personnel must be trained to take care of their oral health in a host of variety of ways.[2]Identification  of  persons  with  mental  retardation  and  affording  them care  and  management  for  their  disabilities  is  not  a  new  concept in  India.  According  to  Persons  with  Disabilities  Act  (PWD),  1995 Mental  retardation  means  a  “condition  of  arrested  or  incomplete development  of  mind  of  a  person  which  is  specially  characterized by  sub-normality  of  intelligence”.  As  a  matter  of  need  and  above all  as  a  matter  of  right,  has  had  its  recognition  only  in  recent  times, almost  after  the  enactment  of  the  Persons  with  Disabilities  Act (PWD), 1995[3].Individuals  with  MR,  have  poor  oral  health  as  compared  to  the general  population  [4]. 

 

The  oral  health  of  the  individuals  with  MR is  associated  with  severity, etiology,  residential  arrangements  and age  of  the  individual  [5]

 

 

A  systematic  method  for  identification  and  screening  of  persons with  mental  retardation  has  been  developed  by  the  NIMH  (National Institute  for  the  Mentally  Handicapped).  They include pre-natal, neonatal and post-natal diagnostic procedures [6]:

 

1) Pre-natal Procedures

a. Blood  tests  for  the  pregnant  mothers  for  any  anemic  condition, diabetes,  syphilis,  Rh  incompatibility  and  neural  tube  defects  in the foetal stage.

 

b.  Ultrasonography  (during  pregnancy)  is  carried  out  in  the second  trimester  of  pregnancy  to  detect  certain  disorders, such as - neural tube defects, hydrocephaly, cerebellar lesions, etc[7]

 

c. Amniocentesis is indicated in cases of foetal chromosomal aberration,  congenital  metabolic  errors,  severe  Rh  incompatibility etc.

 

d.  Chorionic Villous Sampling. 2. 3. Neonatal and Postnatal Screening and Diagnostic Procedure. Blood  and  urine  examinations  are  conducted  in  the  neonatal period  in  all  suspected  cases  and  with  a  previous  history  of mental retardation in the family or cretinism. a. Apgar score at one minute after delivery. b.  Urine  screening  for  metabolic  errors  -PKU  (Phenyl Ketoneuria). [8]

 

e. Blood biochemistry tests for cretinism, rickets, jaundice. d. Blood antibody titres to detect infections. E

 

f. Chromosomal  analysis  for  Down  syndrome,  deletion  of syndromes. Neonatal neurobehavioural assessments. g.  Screening  for  visual  impairments  (visual  acuity,  fundus examination, and retinoscopy). Screening for hearing impairments (Tympanogram, BERA.) Ultra  Sound  Examination:[9]  To  detect  displacement  of  brain midline  structures,  thickness  of  brain  substance,  intracranial hemorrhage, etc in the newborn. Biochemical Tests for identifying metabolic disorders. Electro  Encephalography  (EEG):  EEG  is  a  useful  diagnostic procedure  for  epilepsy,  encephalitis,  severe  degree  of  mental retardation, etc. Computerised  Tomography  (CT):  CNS  CT  is  useful  to  detect congenital  anomalies  like  holoprosencephaly,  agenesis  of corpus callosum, malformations, Magnetic  Resonance  Imaging  (MRI):  for  intra-cranial  pathology and structural abnormalities.[10]

 

Prenatal Prevention relates to

Dealing with causal factors such as Rhin compatibility; maternal illness,  infections  and  other  high  risk  conditions,  such  as malnutrition  in  mother  and  child  during  the  first  trimester  of pregnancy,  environmental  and  occupational  hazards  and consanguinity.

Prenatal diagnosis where preliminary investigations are carried out,  blood  and  urine  tests  investigations  to  assess  the  foetal abnormalities  through  ultrasonography,  radiography,  and amniocentesis.[11]

 

Immunization to the mother for preventing illnesses and infections leading to disability in the fetus.[12]

 

HISTORY:

India  was  the  first  country  to  be  a  signatory  to  the  Proclamation on  the  Full  Participation  and  Equality  of  People  with  Disabilities  in the  Asian  and  Pacific  Decade  of  Disabled  Persons  1993-2002. In  January  1996  an  Act  of  Parliament  enabling  implementation  of this  Proclamation  was  passed  The  Persons  with  Disabilities  (Equal Opportunities,  Protection  of  Rights  and  Full  Participation)  Act, 1995.[13]  Two  other  legislations,  the  Rehabilitation  Council  of  India  Act, 1992  and  the  National  Trust  Act,  1999  have  included  training  and guardianship respectively in their clauses [14]. Technology  for  People  with  Mental  Retardation  and  Associated Disabilities  Assistive  Technology  (AT)  can  be  a  device  or  a  service. An  assistive  technology  device  is  any  item,  piece  of  equipment, or  product  system  that  is  used  to  increase,  maintain,  or  improve functional  capabilities  of  individuals  with  disabilities.  An  assistive technology  service  means  any  service  that  helps  an  individual  with a  disability  select,  acquire,  or  use  an  assistive  technology  device (Assistive Technology Act of 2004) [15].Various studies alsp developed  the  following  is  the  list  indicating  that assistive  technology  may  be  considered  appropriate  when  it  does any or all of the following things Enables an individual to perform functions that can be achieved by no other means.

 

Enables an individual to approximate normal fluency, rate, or  standards – a  level  of  accomplishment  that  could  not  be achieved by any other means. 

 

Provides access for participation in programs or activities which otherwise would be closed to the individual. [16]

 

Increases endurance or ability to preserve and complete tasks  that  otherwise  is  too  laborious  to  be  attempted  on  a routine basis.[17]

 

Enables an individual to concentrate on tasks–learning/ employment, rather than mechanical tasks.

 

Provides greater access to information from various platforms.[18]

Supports normal social interactions with peers and elderly people.

Supports participation in the least restrictive educational environment and a host of other such processes.

People with intellectual disabilities require extreme levels of care from their caretakers and the caretakers should be trained in a variety of different conditions and also levels. They should be advised and trained about the various complications which may get caused due to the intellectual disabilities.[19].

 

The following are some of the various complications which can arise in patients with intellectual disability.

 

Gastrointestinal Conditions:

Helicobacter pylori (HP) infections Many older adults with ID and therefore present at-risk for infectious diseases like hepatitis B, tuberculosis and helicobacter pylori (HP). A study conducted in Canada (Kennedy, 2002) discovered that 80% of participants who had been formerly institutionalized suffered from HP, which was 3–4 times higher than for adults who never resided in an institution[20].A lower percentage (59%) was found among persons with ID living in inpatient units with a range from 22% for persons who stayed shorter than 4 years to 84% for those who stayed longer than 4 years[21]. Other studies also found high rates of HP for people with ID, such as 77% for institutionalized residents and 78% for those previously living in institutions and 44% for those with no history of institutional care.[21]Several reports reported an HP rate of 87% among institutionalized persons with ID living in various institutions. These HP prevalence rates for persons with ID are higher compared with the general population where rates vary from 25–30%.[22]. Constipation is another common gastro intestinal disorder which is commonly observed in the patients with intellectual disabilities. Constipation was most commonly observed in patients with ID when compared with the general population. The various reasons for this may be due to the following reasons such as immobility, as well as cerebral palsy, neurological disease, use of specific drugs, and physical inactivity were risk factors for constipation, rather than the normal aging process itself.[23].

 

Thus gastro intestinal conditions are more prevalent in patients with ID when compared with the general population.

 

Musculoskeletal Conditions:

CMD stands for congenital musculoskeletal disorders. This is another of the most common disorders which are associated with ID. This is more common in these cases when compared with the general population.[24].

 

In a survey of adults with ID over the age of 40 years found an increased frequency of musculoskeletal conditions with increasing age, mostly related to osteoarthritis and osteoporosis[25]. Similar results were reported both in institutional and community settings. Another study of the pattern of functional abilities and decline of skills in adults with cerebral palsy over 60 years of age[26]. Among those adults who were ambulant in adulthood, there was a marked decline with age. Survival of people who had lost mobility in later life was poorer than for those who still maintained it[27]

 

Osteoporosis

Some adults with ID are at greater risk of osteoporosis because of their high levels of inactivity, low levels of exposure to sunlight, and high levels of anticonvulsant drug use.[28]. Osteoporosis is a significant risk factor for fractures in people who are mobile and have the potential to fall if left unsupervised. Osteoporosis is more prevalent in people with ID when compared with the general population. Osteoporosis is nothing but bone brittleness that is usually caused due to aging due to inadequate levels of calcium in the body.[29].Factors associated with osteoporosis are small body size, hypogonadism, and Down syndrome. Individuals with Down syndrome are at especially high risk due to a lower-peak bone mineral density (BMD) and low muscletone.[30].Several examinations of bone density and fragility fractures among people with ID living in one residential center and found that 78% had osteoporosis.[31].The authors concluded that the reduced areal BMD is in part a consequence of the reduced body size, particularly at the femoral neck.[32].

 

Apart from all these and also several other conditions, there are also various oral problems that can arise. Some of them are,

 

Gingivitis

Another common oral health problem among adults with ID is gingivitis with an incidence being 1.2–1.9 times higher than in the general population.[33].Other studies report prevalence estimates of gingivitis in the range of 6–97% among persons with ID compared with estimates of 8–59% in the general population. While it is believed that older adults tend to have higher prevalence estimates found the prevalence of gingivitis to vary with age (42% among 8–17 years, 58% among 18–34 years, 62% among 35–50 years, and 48% among 51–70 years) for participants at the 2003 World Summer Games. Higher levels of gum inflammation were also reported for older participants of the UK Special Olympics.[34].Gingivitis is found in increased proportions in people with ID when compared with the general population. Gingivitis is nothing but inflammation of the gums.

 

Periodontal disease:

Periodontal conditions may have deleterious effects beyond oral discomfort for adults with ID. In the general population, studies are emerging linking periodontal disease with coronary artery disease. Although data are limited with respect to the rates of periodontal disease among adults with ID, it appears to develop earlier in adults with Down syndrome and is more rapid and extensive than in age-matched persons from the general population[35]. In spite of similar oral hygiene and gingival measures in a controlled study persons with Down syndrome had a higher prevalence, extent and severity of periodontitis than the control group. As poor oral care among adults with ID can lead to diseases that may become life threatening, this is an area requiring further investigation.[36]

 

Tobacco use and exposure While tobacco use, whether through smoking or chewing is probably at low frequency among adults with severe to moderate ID resident in congregate care where more controls are exercised community-dwelling adults, particularly those with mild or marginal ID, show higher rates.[37]. However, more problematic is exposure to second-hand smoke, particularly when adults live or work in settings where staff or visitors are permitted to smoke[38]. Studies found that as community-dwelling adults with ID are three times more likely to live in poverty, they are more affected by the financial expense of tobacco use, and that their use of tobacco use may decrease the effectiveness of the medications they take.[39]. Tobacco addiction may have begun when older adults were institutional residents and tobacco was dispensed as a “reward. Studies also note that on the occasions when adults with ID are offered access to smoking cessation programs, they may fail as they may have difficulty understanding the health information presented to them. With this in mind, some efforts to provide stop-smoking education information adapted for adults with ID have emerged. Problematic also are high BMIs and coincident smoking or exposure to second hand smoke, which have been linked to higher rates of asthma. As these studies show, the health risks associated with tobacco use or exposure are of concern for patients with ID.[40].

 

Adults with Down syndrome are more at risk for being overweight. Several Studies suggest that 25–48% of adults with Down syndrome are obese and also there are other conditions which are associated with these disorders. Adults with Prader Willi syndrome are also at risk for morbid obesity and those who are morbidly obese have been found to have significantly lower cognitive function and more behavior problems[41]. Eating practices such as consuming high-fat foods and not eating fresh fruits and vegetables likely play a role in the development of excessive weight and obesity and elevated risk for CVD and diabetes among adults with ID[42]. Being low-income and poorly informed about sound nutritional practices, as reported for the majority of adults with ID  may limit access to healthy food and sound food choices. Nutritional practices among adults with ID living independently may be less than ideal and this finding may apply also to those living in congregate care. For example, studies of adults with ID in the U.S. who resided in group homes indicated that they consume a diet that is high in carbohydrates and fat, and low in fruits and vegetables.[43].These are some of the risk factors associated with persons with ID.

 

CVD is the most common cause of death, but there are no indications of excess mortality or morbidity due to CVD in older adults with the ID. With regard to risk factors, relatively low rates of hyperlipedemia and hypertension and adult-onset diabetes are reported.[43]. This could be a real picture of the situationor a false one due to under-diagnosis. Health problems including CVD related to smoking, alcohol, and use of non-medical drugs are still quite uncommon. In group homes, adults of all ages, including the elderly, consume a diet that is high in carbohydrates and fat and low on fruit and vegetables. Lack of information and education among staff and lack of money to purchase healthier but at times more costly food could be possible explanations.[44].

 

Health care personnel who are treating and taking care of the persons with ID must be trained in various aspects concerned with health care and must provide the most successful health care for people with ID.

 

CONCLUSION:

Identification  of  persons  with  mental  retardation  and  affording  them care  and  management  for  their  disabilities  is  an  urgent  need  of  time. Attitude  and  knowledge  of  the  oral  health  professionals  and  is  of utmost  importance  while  rendering  the  oral  health  care  to  mentally handicapped  people.  Dental  team  should  be  aware  of  the  problems faced  by  mental  handicapped,  dentist  should  have  good  patient relationship with his patients.

 

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34.     Agarwal  AK,  Sharma  VP.  Rehabilitation  Management  of  Mentally  Retarded.  Indian Journal of Physical Medicine and Rehabilitation.2002;3538.

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40.     Morris,  S,  Benjamin,  S,  Gray,  S  and  Bennett,  D.  Physical,  psychiatric  and  social characteristics  of  the  temperomandibular  disorder  pain  dysfunction  syndrome:  the relationship of mental disorders to presentation.  Br Dent J.1997;182(7):25560

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