CHAPTER 5. DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
5.4 Future Research
144 5.3 Implications of the study
In Australia, there has been limited dental research on people with disabilities. Although the findings of this study are not definitive (given the study limitations discussed above), they do suggest several implications for public health, health care and research. Thus the findings of this study:
• Have demonstrated the extent of the oral health problems, impacts of oral heath on quality of life, shortcomings in preventive dental practices and barriers to accessing clinical care and identified disability-associated oral disease risk factors.
• Have highlighted the important role of carers as valuable health care team members and that they need additional support in terms of training and incentives regarding oral health care.
• Challenge the dental profession to train adequate number of dentists and hygienists in special needs dentistry to meet the needs of this growing population of people with disabilities.
• Call for the government to establish dental fee assistance/waivers programmes to assist this very disadvantaged population.
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health services. Health services research examines the use, costs, quality, accessibility, delivery, organisation, financing, and outcomes of health care services (Hadley, 2000).
Considering the current issues with the increasing numbers of people with disabilities in accessing oral health care and clinical management of oral disease, one of the strongest mandates for such populations are oral health promotion and disease prevention. However, most care recipients are dependent on the carers for their daily oral hygiene care, diet and dental visits. Carers are also responsible for communicating with health care providers, organising appointments and medications and making treatment decisions and providing consent on behalf of their care recipients. Oral health literacy among carers could be the contributing factor to their knowledge, attitude and behaviours on which their care recipients are so highly dependent on and this is another area that could be explored to explain variations in the oral health of people with disabilities.
146 5.5 Conclusions
Based on the main findings of the study, with reference to the three specific aims, the following conclusions were drawn.
Characteristics of care recipients
In addition to the main disabling conditions like intellectual disability, autism and cerebral palsy, nearly 50% of the care recipients had other disabling conditions like epilepsy, diabetes, and hearing and visual impairments. Almost a third of the care recipients had little or no effective communication and one fifth of them communicated non-verbally. Over 62% of the care recipients always needed help with one or more self-care activities. A disability support pension was the main source of income for the majority of the care recipients. All of these factors make this population dependent on their carers for their general well-being and health care.
Perceived oral health and treatment needs and impacts on quality of life
About 50% of carers thought that their care recipients presently had an oral health problem and needed dental treatment. The most frequent oral health problem reported was bad breath followed by tooth problems and bleeding gums.
The most frequent perceived treatment need reported was scaling, followed by fillings. In spite of the fairly high prevalences of perceived oral health problems and treatment needs, the prevalence of negative impacts reported from a dental problem was low. However, carers at family homes reported more negative impacts compared to carers from other settings. The marked discrepancy in the proportion of carers reporting a negative impact on quality of life and the presence of a clinically-defined oral health problem may be an indication of an underestimation by carers of pain and suffering among their care recipients or carers not being aware of signs of oral pain due to lack of training in the recognition of such manifestations.
Preventive dental practices and barriers
The predominant method of oral hygiene care was toothbrushing, with very few care recipients using preventive measures like fluoride/chlorhexidine gels or mouth rinses. The majority of the care recipients needed partial or complete assistance from their carers for cleaning their teeth, with care recipients at institutions being most likely to need such assistance. Nearly 40% of the care recipients had their teeth brushed once a day or less,
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which was more common among care recipients at family homes who also reported inadequate time to clean compared to those in community housing and institutions.
Most residents at institutions visited the on-campus dentist every six months. A much lower percentage of care recipients from community housing and family homes received six monthly dental visits. Many parents were not even aware of dental services available for their care recipients after 18 years of age. Other carers reported problems of accessing dental care due to lack of dentists with adequate skills in managing people with disabilities followed by cost, location of dental clinic, lack of dentists willing to treat people with disabilities and transportation problems. Nearly 19% of the care recipients required a general anaesthetic for examination and treatment, while 13% were treated in the chair under sedation.
Oral disease risk behaviours
Sweetened tea/coffee was the most frequently consumed food. Nearly 50% of them drank soft drinks/cordials more than once a day. A higher proportion of care recipients at institutions took a high intake of sweet drinks compared to care recipients at other settings.
The majority of the care recipients took one or more medications, most of which have been associated with dry mouth and candidiasis, or gingival hyperplasia or mucosal problems. The proportion of care recipients taking such medications with potential adverse effects was higher at institutions than those at family homes and community housing.
Very few care recipients were reported to be current smokers or past smokers. However, clenching, grinding or tapping teeth was present in almost a third of the care recipients.
Nearly 10% placed food/medicine/other products in the mouth for lengthy periods of time, 8% regurgitated, re-chewed and re-swallowed food, while 5% craved for and ate non-edible substances like cigarette butts.
Carer characteristics
There was almost equal representation of family and non-family carers. Over 82% of them were females and just over 33% above 55 years of age.
Knowledge and attitudes of carers
Only a few carers had received training in oral care and less than 50% of them wanted training in oral hygiene care for people with disabilities. The training received was short and not current. However, most of the carers thought oral health care is important for them and their care recipients and were comfortable providing care.
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Care provided to care recipients, including continuity of care and its effects
Most of the carers in all three settings always/sometimes provided assistance with self-care activities, with over 50% of them being the primary carer for over 10 years. Less than 49% of carers were able to clean all teeth for their care recipients, possibly due to one or more behavioural difficulties among the care recipients. Time spent per cleaning session ranged from less than a minute to over 6 minutes, which was adequate for most of them, but more family carers reported inadequate time to clean teeth compared to carers at other residential settings. Lack of staff and lack of communication among staff were additional difficulties for paid carers in providing oral hygiene care for their care recipients.
In spite of many carers working over 100 hours a week, the majority of them reported being satisfied with their caring role. However, they also reported to have been stressed, weary and experienced muscle pain in neck/back/limbs.
Over 50% of the care recipients were cared for by two to four carers, with more care recipients at community and institutional settings cared for by more than five carers on a daily basis, compared to those at home, most of whom were cared for by one or two to four carers.
Most carers at family homes had only one care recipient under their charge, while most carers at community and institutional settings cared for two or more care recipients.
Oral health status and factors influencing the oral health status of care recipients
The prevalence of untreated decay among the care recipients in South Australia was 17% and 76% had past and present caries experience. None of the examined subjects wore a removable prosthesis, although nearly 50% had one or more missing teeth.
After adjusting for all potential confounders, there was no statistically significant difference in untreated decay, missing teeth, filled teeth, caries prevalence or mean DMFT between care recipients at the three residential settings. This finding therefore failed to support the alternate hypothesis that oral health would be poorer among care recipients in institutions. However, untreated decay was significantly associated with moderate and high intake of sweet drinks and never visiting the dentist or visiting only because of a problem. Missing teeth were significantly associated with requirement for a general anaesthetic for dental treatment and having low and high weekly hours of care. Filled teeth were significantly associated with 35–44 age-group, lack of oral hygiene assistance from carers and high weekly hours of care.
Caries prevalence was significantly associated with 35–44 age-group, lack of oral hygiene assistance from carers and high weekly hours of care. Mean DMFT was significantly
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associated with 35–44 age-group, autism, intellectual disability, and high weekly hours of care.
Anterior tooth wear was found in 45% and posterior tooth wear in 24% of care recipients.
Care recipients in the community were more likely to have posterior tooth wear compared to those in family homes. Anterior tooth wear was significantly associated with older age-group and rumination.
Oral hygiene and gingival status were poor with the prevalence of extensive plaque at 40%, extensive calculus at 42% and extensive gingivitis at 36%. Residential setting was not associated with oral hygiene and gingival status. However, extensive plaque was significantly associated with 35–44 age-group, poor to fair general health, habit of placing food/medicine/other products in mouth for lengthy periods of time, care recipients cared for by male carers, and care recipients with high weekly hours of care. Extensive calculus was significantly associated with older age-group, while extensive gingivitis was significantly associated with always needing help for self-care activities from carers.