In this study, the terms "persons with disabilities" and "care recipients" have been used interchangeably as appropriate. Determinants of oral health for people with disabilities will be similar to those of the general population.
Aims and objectives
Hopefully, this will raise awareness of the oral health status of this underserved population and generate interest and action among key stakeholders to help improve the capacity of service providers to meet the oral health needs and improve the quality of life of people with disabilities . . Emphasizing the important role of caregivers can also help to ensure that they are recognized as valuable members of the healthcare team and provide an incentive to continue caring for people with disabilities with dedication.
Hypothesis
The pathways shown in the framework conceptualize the oral health status of care recipients as influenced by several factors. Continuity of care can also have an impact on the quality of care received by care recipients and thus on their oral health.
Oral health of adults with physical and intellectual disabilities
- Dental caries
- Tooth wear
- Periodontal problems
- Other oral health problems .1 Oro-facial trauma
In another British study, Cumella et al. 2000) examined 50 adults aged 25-44 with intellectual disability drawn from a special needs register in Warwickshire and reported that 58% of subjects had untreated relapses. In another UK study of a group of 50 adults with intellectual disability (25–44 years) drawn from a special needs register living in the community, who were not in contact with the Community Dental Service, Cumella et al.
Perceived oral health needs
However, among a group of 124 adults with intellectual disabilities (21-40 years), Gabre et al. 2001) found no link between medication use and dental caries, even though almost half of the subjects used medications that could cause hyposalivation. However, dental professionals make treatment plans and decisions based on their own perception of the patient's quality of life, and there may be a low correlation between the professional's perception and that of the patient (Gift and Redford, 1992).
Oral health-related quality of life
From an evaluation of proxy responses to the Stroke Impact Scale, Duncan et al. 2002) suggest that agreement is best for observable rather than subjective characteristics. The closer the caregiver's personal relationship with the care recipient is, the more valid the information (Nelson et al., 1990).
Influences on the oral health of people with disabilities .1 Care recipients
- Disability, general health and oral health
- Living arrangements
- Oral disease risk behaviours
- Carers
- Reasons for taking on primary caring role
- Knowledge, attitude and behaviour of carers
- Continuity of care
- Effects of caring role
The most commonly reported reason for dental visits is the caregiver's suspicion that the care recipient may be experiencing pain (Hennequin et al., 2000). People with disabilities may place food in the mouth for extended periods of time, increasing the risk of caries (Perlman et al., 1991).
Summary
It describes the study design, sampling frame and data collection methods, provides details of mail questionnaires and oral surveys of care recipients, and an overview of the analytical approaches undertaken.
Study design
Sampling frame Target population
- Sampling organisations associated with people with disabilities
- Sampling people with disabilities for mail questionnaire
- Sampling people with disabilities for oral epidemiological examinations
Beginning in February 2005, participating organizations were asked to send an information package with envelopes to the primary caregiver of each registered care recipient in their database. In some cases, there were two responses for the same care recipient from two care providers at different organizations, because the care recipient was affiliated with both organizations.
Mail questionnaire to carers
Some needed specifying figures – number of carers providing daily care to the main care recipient, number of care recipients under responsibility.
Oral epidemiological examinations of care recipients .1 Appointment for oral examination
- Oral examination procedure
- Report of the oral examination
1= plaque present on some, but not all, approximal, buccal and lingual surfaces of the tooth. 2= plaque, present on all approximal, buccal and lingual surfaces of the tooth, but on less than half of these surfaces.
Data management
- Recording of medications
- Data weighting
- Response formats
- Analyses
For example, carers from Autism SA who live in communal housing were given a weighting of 2.7 instead of 7.5 for the questionnaire and those from Minda Inc. Likewise, care recipients surveyed from Autisme SA who live in communal housing were given a weight of 5.7 instead of 15.0 for the survey and those from Minda Inc.
Ethical implications and approvals
Age and gender were included in all models, even when bivariate relationships showed associations to be non-significant. Family home was the reference group, thus estimating the effects of institution and community institutions, each relative to family home. The effects were expressed as odds ratios for oral health outcomes described as proportions, and parameter estimates of mean differences for DMFT.
At each step, if the difference in parameter estimate for the three residential settings was greater than 10%, the variables were considered confounding and retained and the next block of variables was added to the new model, otherwise they were removed from the model. In the final model, odds ratios and 95% CI are reported for community housing and institution relative to family home and other significant variables.
RESULTS
Information from organisations
Response
- Questionnaire to carers
- Oral examination of care recipients
Among the 485 respondents to the questionnaire, oral examinations were carried out for 267 care recipients (family home= 76, community accommodation= 93, institution= 98). The main reasons for not participating in oral examinations were that carers thought it would be impossible due to aggressive or resistant behavior or that it would cause unnecessary distress to the care recipient. Among the people whose caregivers accepted an examination, 17 could not be examined by the study dentists because of behavioral problems of the care recipients.
Some visited private dentists or other SADS clinics and their carers said they did not want to be examined, while some failed to attend or canceled up to five times, citing illness as the main reason. Some gave no contact details, while others did not respond to multiple phone messages.
Analyses
- Characteristics of carers
- Characteristics of care recipients
- Perceived oral health problems and treatment needs of care recipients and impacts on quality of life
- Dental practices among care recipients .1 Toothbrushing pattern
- Dental visit pattern
- Oral disease risk behaviours among care recipients .1 Diet
- Medication usage
- Prevalence of other risk behaviours
- Knowledge, attitude and behaviour of carers across residential settings .1 Knowledge
- Attitude of carers to oral health
- Dental behaviours of carers
- Care provided, continuity of care and effects of caring role on carers .1 Care provided and continuity of care
- Effects of caring role on carers
- Carer burden
- Dental status
- Relationship between dental status and care recipient characteristics
- Relationship between dental status and dental practices of care recipients
- Relationship between dental status and potential risk factors Potential risk factors for oral health include diet and medications
- Relationship between dental status of care recipients and carer characteristics The prevalence of all five measures of caries among the care recipients did not vary by age
- Relationship between dental status of care recipients and continuity of care There was no significant association between measures of caries and: how often carers
- Tooth wear
- Relationship between tooth wear and care recipients
- Relationship between tooth wear and oral habits of care recipients
- Summary of findings on tooth wear among care recipients
- Periodontal status
- Relationship between periodontal status and care recipient characteristics
- Relationship between periodontal status and dental practices of care recipients Dental practices of care recipients included toothbrushing patterns and dental visit patterns of
- Relationship between periodontal status and risk factors
- Relationship between periodontal status and carer characteristics
- Relationship between periodontal status and continuity of care
- Multivariate logistic regression models: factors associated with untreated decay among the care recipients
- Multivariate logistic regression models: factors associated with missing teeth among the care recipients
- Multivariate logistic regression models: factors associated with filled teeth among the care recipients
- Multivariate logistic regression models: factors associated with caries prevalence (DMFT>0) among the care recipients
- Linear regression models: factors associated with caries experience (mean DMFT) among the care recipients
- Multivariate logistic regression model: factors associated with anterior tooth wear among the care recipients
- Multivariate logistic regression model: factors associated with posterior tooth wear among the care recipients
- Multivariate logistic regression model: factors associated with extensive plaque among the care recipients
- Multivariate logistic regression model: factors associated with extensive calculus among the care recipients
- Multivariate logistic regression model: factors associated with extensive gingivitis among the care recipients
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
Results and comparison with previous studies
- Results from mail questionnaire .1 Care recipient characteristics
- Perceived oral health problems and treatment needs of care recipients and impact on quality of life
- Dental practices
- Frequency of risk factors and behaviours Diet
- Socio-demographics of carers
- Care provided, continuity of care and effects of caring role
- Results from oral epidemiological examination
- Influence of residential setting on oral health of care recipients
In this study, a higher proportion of institutional care recipients received help with brushing their teeth from their caregivers than other settings. Of the few care recipients who used mouthwash, it was used more frequently among those living in the community compared to those in family homes and institutions. The low use of mouthwashes may be due to the inability of care recipients to rinse.
Care recipients in institutions visited the dentist more often (semi-annual recall) compared to care recipients in other institutions. This behavior of irregular brushing was reflected in the frequency of tooth brushing of their care recipients. The low prevalence of untreated tooth decay could be a consequence of the regular dental care provided to the care recipients in this study.
Bivariate analysis showed that care recipients' general health was significantly associated with extensive plaque, calculus, and gingivitis. Care recipients cared for by male caregivers were 3.9 times more likely to have extensive plaque compared to those cared for by female caregivers.
Methodological strengths and limitations of this study .1 Study design and sampling
- Questionnaire
- Oral examination
- Proxy-reported data
- Recording of oral examination
In the real situation, care recipients are often looked after by more than one carer. A carer may also have been the primary carer for two or more care recipients and therefore responded on behalf of all of them. From a total of 1280 invitations to participate in the study, responses were obtained from carers of 485 care recipients.
Some of them wrote that the survey was intended for care recipients and that their information was none of our business. In addition, the majority of care recipients surveyed were already receiving regular dental care from SADS dentists at the Adelaide Dental Hospital, Strathmont Center and Julia Farr Services. The questionnaire in this study was too long and complex to be administered directly to care recipients with significant cognitive impairment.
All examinations were performed at the time of routine dental examination of the care recipients. The majority of the investigations (216) were conducted by AP who examined care recipients from all three residential institutions.
Future Research
Almost a third of care recipients do not or hardly communicate effectively and a fifth communicate non-verbally. More than 62% of care recipients always needed help with one or more self-care activities. For the majority of care recipients, a disability pension was the main source of income.
Around 50% of carers believed that their carers currently had an oral health problem and needed dental treatment. The majority of care recipients took one or more medications, most of which have been associated with dry mouth and candidiasis, gingival hyperplasia or mucosal problems. However, clenching, grinding or throbbing teeth were present in almost a third of the care recipients.
However, most caregivers felt that oral care was important to them and their care recipients and felt comfortable providing care. Care recipients in the community were more likely to have tooth wear compared to those in family homes.
Recommendations
However, extensive dental plaque was significantly associated with age group 35–44 years, poor to poor general health, habit of putting food/medicine/other products in the mouth for long periods of time, residents cared for by male caregivers, and residents with many weekly hours of care. This study found that there are several factors that affect the oral health of people with disabilities. Reducing the frequency of sugary drinks; regular visits to the dentist; ensuring adequate contact between caregivers and patients, but avoiding burdening caregivers; and includes appropriate administrative supervision and assistance with daily oral hygiene care.
Managers must ensure that caregivers have adequate time with their care recipients to build trust and rapport, but must be careful not to be overwhelmed so that optimal care is provided for their care recipients. Establishing a database of dentists willing to treat persons with disabilities should assist caregivers in locating dentists and obtaining necessary dental care for their care recipients. One way to overcome the cost barrier is if dental care could be included in Medicare to cover dental care for people with disabilities.
Appropriate referrals should be arranged from the SADS School Dental Service and the Women's and Children's Hospital to the Special Needs Unit of the Adelaide Dental Hospital after care recipients cease to be eligible for services in their care, to ensure continuity of care into the to ensure maturity. The provision of on-campus dental services should continue in institutions to maintain accessibility to clinical care for people with disabilities moving into the community.
