CHAPTER 5. DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
5.1 Results and comparison with previous studies
5.1.1 Results from mail questionnaire .1 Care recipient characteristics
5.1.1.3 Dental practices
Another hypothesis of this study was that dental practices (toothbrushing and dental visit patterns) among care recipients vary among residential settings.
Toothbrushing pattern
In this study, a higher proportion of care recipients at institutions received assistance for toothbrushing from their carers than other settings. Compared to the UK study of adults with intellectual disability by Cumella et al. (2000), which reported 22% of subjects with intellectual disability needed assistance from their carers for oral care, carer involvement was much higher in this study at 72%, suggesting care recipients in this study were comparatively more dependent.
In this study, infrequent toothbrushing was more common among care recipients at family homes compared to community housing and institutions, with more carers at family homes reporting inadequate time to clean compared to carers at other settings. This may reflect greater carer burden in family settings, and suggests that parents require additional support (eg. financial, physical and respite) in the provision of oral hygiene care at home.
The use of cleaning aids such as toothbrushes, toothpaste and gels was similar across the three settings. Less than 10% used gels or mouth rinse and although asked in the questionnaire, very few of them specified they used fluoride or chlorhexidine. Of the few care recipients who used mouthrinses, it was more commonly used among those at community housing compared to those at family homes and institutions. The low use of mouthrinses could be due to the inability of the care recipients to rinse. Where provision of daily oral hygiene by carers is inadequate or not possible due to behavioural problems, use of fluoride to prevent decay and chlorhexidine to maintain gingival health has been encouraged (Glassman and Miller, 2003). For care recipients who can not rinse or spit out the solution, swabs (Siefel et al., 1992) or sprays (Burtner et al., 1991) can be used.
Compared to the French study by Faulks and Hennequin (2000) of children and adults with physical and intellectual disabilities aged 6–50 years, infrequent toothbrushing among the care recipients in this study was half as low (39% versus 79%) and the use of toothpaste with toothbrush for cleaning their teeth was much higher (93% versus 71%). Cleaning ability of carers was also better, with carers in this study able to clean all teeth for 46% compared to
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only 24% of care recipients in the same study. Cleaning ability among carers for their care recipients was similar across the three settings.
There were several organisational barriers to providing oral hygiene care, such as lack of time in usual routine for all carers and lack of staff and lack of communication among staff between shifts for non-family carers. Family carers should therefore be provided with some assistance at home. Among non-family members, effective communication among staff between shifts should be encouraged using communication books or logs of personal hygiene including oral hygiene, so that oral hygiene care for their care recipients is not compromised.
Some behavioural difficulties were also reported by carers when providing oral hygiene care, the most frequent being inability to rinse with mouthwash. Similar problems were reported by Faulks and Hennequin (2000), which included constant movement, chewing tooth brush, refusing to open mouth and gag reflex.
Toothbrushing is a basic yet important marker of good oral health and is considered the most reliable means of controlling plaque, provided cleaning is adequate and performed daily (Loe, 2000). However, people with disabilities depend greatly on their carers for their daily oral care. For some care recipients, it is not realistic to provide oral hygiene care on a regular, daily basis as ideally needed due to behavioural problems. It may only be possible to provide oral hygiene care ‘as best as possible’ at ‘unpredictable times’. Whether this was the reason for infrequent toothbrushing could not be confirmed by the results of this study.
Family carers and managers of community housing and institutions should be made aware of this high prevalence of infrequent toothbrushing and the low use of preventative aids among the care recipients. These findings highlight the need for oral health promotion, training and assistance among carers to improve oral care for people with disabilities.
Dental visit pattern
Care recipients in institutions visited the dentist more frequently (six-monthly recalls) compared to care recipients at other settings. This was possible due to formal arrangements between the institutions and SADS, whereby a dentist and a hygienist visit the institution every week. Overall, 74% of the South Australian population represented in this study visited the dentist at least once a year which was comparable to the earlier Australian survey of adults with developmental disabilities by Scott et al. (1998) and the UK study of handicapped adults by Francis et al. (1991) which reported the dental visit in the last 12 months as 65%
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and 69% respectively. However, in this study, nearly 19% of care recipients had never visited the dentist or not after turning 18 years of age or visited only because of a dental problem, of which 78% of them were from family homes. Some of the reasons were no dental problem, appointments for check-ups unavailable, unable to find a dentist who will see people with disabilities, care recipients can not tolerate dental procedures, cost and transportation difficulties.
A general anaesthetic was required more often for care recipients from family homes, while oral sedation was required more often for care recipients from institutions mainly for behaviour management, rather than the complexity of the dental treatment. Overall, fewer care recipients (18% versus 25%) needed a general anaesthetic than that reported by Francis et al. (1991). Due to the risks, cost and long waiting periods associated with dental treatment under a general anaesthetic, greater emphasis should be placed on preventive measures.
Carer involvement at dental visits occurred in over 76% of cases compared to 61% of cases in the UK survey by Cumella et al. (2000). It was a practical necessity in making and keeping appointments as most care recipients were unable to do so, on their own. Carers from family settings were most likely to be present at the dental visit compared to carers at other settings.
Most frequent reason for carers from other settings not taking their care recipients for dental visits was not being rostered. Whenever possible, the same carers should accompany the care recipients so that the carer can provide additional information and support, whenever needed.
Also, they can see for themselves the problems if any, how they were managed by the dentist and learn how the problem can be prevented in the future.
The frequency of usual services received by care recipients in this study was also higher than in the earlier Australian survey by Scott et al. (1998), which examined 101 adults with developmental disabilities between 21–53 years. Despite the younger age-group in the current study, the percent reporting dental examination was much higher (73% versus 39%) in the study by Scott et al. (1998). Similarly, the percentage with fillings was higher in this study (39% versus 30%). Scott et al. (1998) reported that 46% of the study participants had received teeth cleaning and polishing while 8% had received periodontal treatment. When added together, those two percentages were lower than the 59% of care recipients in this study who reported receiving scaling and cleaning. Surprisingly, extractions were not reported in that study. Care recipients at institutions received significantly more scaling, fillings and extractions as they visited the dentist more frequently than care recipients at other settings.
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Cumella et al. (2000) reported only four carers with problems obtaining dental care, which was attributed to dentists’ unwillingness to treat people with intellectual disability. In contrast, in this study there were over 43% of carers who reported one or more problems in obtaining dental care, the most frequent being lack of dentists with adequate skills in managing people with disabilities. Carers at family homes experienced the most number of problems, while those at institutions reported minimal problems in obtaining dental care for their care recipients. Again, this was possible due to the formal arrangement with the institutions and SADS, whereby care recipients had access to care for relief of pain on the same day or at least within a week and for routine dental check-up every 6 months.
However, some carers at institutions acknowledged that there were too many patients to be seen by one dentist in one morning every week. In Australia and overseas, there is a lack of clinical training for undergraduate and postgraduate students in the management of people with disabilities. In fact, Special Needs Dentistry was recognised as a speciality in Australia only in 2006.
Cost was yet another problem mentioned by some carers. Although eligible to be treated at a concession rate at government clinics, with the introduction of co-payments, the cost of a general course of dental treatment could reach Aus $178.00, which may not be affordable to all.
Lack of suitable transportation, especially for wheel-chair bound care recipients and inadequate disabled parking outside dental clinics resulting in late arrivals for appointments were problems exclusive to those living at family homes and community housing. As services are provided within the institution, care recipients at institutions have no transportation and parking problems.
Other problems included carers not being aware of services available for people with disabilities and not knowing where to take their care recipients, or having the impression that there was a long waiting list to be seen at government clinics. There is a need to raise awareness about the importance of oral health and clinical services available for people with disabilities among relevant organisations and family carers via formal and informal meetings and discussions. Perhaps, organisations associated with people with disabilities should have a referral directory that includes dental services for this sub-group of the population. Also, formal arrangements could be made for appropriate referrals from the SADS School Dental Service and the Women’s and Children’s Hospital to the Special Needs Unit at the Adelaide Dental Hospital, after care recipients are no longer eligible for services under their care, to
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ensure continuity of care into adulthood. Where care recipients are compliant, government clinics should arrange priority recall visits to this disadvantaged sub-group of the population as most of them would not understand the concept of a waiting list and would not be asking to be put on such lists and even if they were, would still depend on their carers for arranging the appointment and making the visit.
Location of services received by care recipients was not queried as it was assumed that most people with disabilities are eligible for public dental service and are seen at SADS clinics.
However, on contacting carers for an appointment for an oral examination, there were 22 care recipients who saw private practitioners on a regular basis, of which only 9 agreed to participate in the study. Most of them had private health insurance.
Most carers reported that the dentist/hygienist showed sensitivity to the special needs of their care recipients, conducted a proper dental examination, diagnosis and treatment, fully explained treatment choices, offered clear oral hygiene instructions to them and care recipients, and arranged recall visits for their care recipients. Generally, most carers had positive reports, however, family carers were either more neutral or negative about their reports compared to carers from other settings, problems with cost, transportation and lack of services available, as discussed above, being the probable reasons.
This is the first study that has attempted to compare dental practices in this population across the three residential settings. Managers of institutions should note the regular oral health care that their care recipients are receiving at the institutions and ensure that level of care is continued when they are moved into the community. Carers at community housing and family homes should have access to information on services available through support organisations with which they are associated, and subsequently access to regular dental visits.
5.1.1.4 Frequency of risk factors and behaviours