3.1. Oral health Care of the Pre-school and School Age Child

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Prevention and Promotion of Oral Health
• The consumption of sugary foods and drinks should be limited to meal times.
• Cariogenic snacks should be avoided between meals(5).
• Collaboration between dentists and dieticians will ensure that appropriate preventive advice is offered
• Sugars should not be added to bottles of infant formula or follow-on formula.
• Sugary drinks should not be given in bottles or feeders, especially at bedtime.
• Infants should not be left to sleep with a bottle containing sugary or acidic drinks, which will lead to dental decay and erosion of tooth enamel (100).
• Prolonged use of feeding bottles should be avoided.
• Fruit flavoured sugar containing drinks should be limited to meal times.
• Parents should be advised that some baby juices are acidic.
• Ensure that, as far as possible, when medicines are given they are sugar-free (102).

A>

Use of Fluoride
• Fluoride toothpaste should be used (6)
• Children over the age of 6 years should be encouraged to use standard (1000ppm) fluoride level toothpaste (99)
• Direct supervision by an adult is advisable (99).
• Parents should be fully involved in the decision to supplement fluoride levels (99).
• The risks and benefits should be carefully explained so that parents can make an informed choice.
• Professionally applied topical fluoride should be biannual (6).

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Oral Health Education
• Instruction in oral hygiene and motivation are important.
• The dental team should appreciate the everyday problems encountered by parents who are attempting to implement a good oral health care routine.
• The causes of gingival bleeding should be explained.
• Oral hygiene programmes should include supervised toothbrushing sessions.
• Oral health education should be given to parents and support services.
• Use of chlorhexidine mouthwash or spray over short periods can be beneficial. (153; 154).

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Education and Training of Parents, Carers and Professionals
• Parents and professionals need to be aware of the possibility of dental pain.
• A dental opinion should be sought for unexplained changes in a child’s behaviour.

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Initial Visit
• An oral health care plan should be agreed with parent/carer/child.

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Regular Attendance
• Regular visits and reviews should be established (60) and tailored to individual needs.
• Acclimatisation to dental treatment should be provided.
• Provision of regular monitoring is the key to the prevention of pain and infection.

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Oral Health Screening
• Oral health assessment should be included as part of general health assessment.
• Screening programmes should be developed and sustained in special schools and special needs units in mainstream education.
• Local programmes and dental services should be developed that address the demographic and geographic needs of the local population.
• The increased use of mobile dental units in mainstream and special schools should be explored.where appropriate.

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Fissure Sealants
• Children at risk of dental caries should have fissure sealants applied to permanent teeth (6) soon after eruption.
• Parents should be advised of the need for regular monitoring and maintenance of fissure sealants (6).

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Working with Schools
• Oral health education programmes should be established in special schools and units.
• Oral hygiene should be included in the child’s Individual Educational Plan.
• Oral hygiene should be included in personal hygiene training.
• Healthy eating policies should be promoted in schools(114).

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Oral Care and Treatment Strategies for the School–Age Child:
• A friendly and supportive clinical environment should be provided.
• Continuity of dental personnel and a team approach should be maintained.
• Children should be acclimatised to the clinical environment gradually.
• Each step of any treatment should be explained clearly.
• Disability awareness training including learning disability for the dental team should be available.
• Equal access to dental treatment under sedation and general anaesthesia should be available.
• Access to emergency treatment under general anaesthesia for pain relief should be provided.
• Increased resources for treatment under sedation and general anaesthesia should be made available.
• Home visits should be provided when required.

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Orthodontics
• Refer early with comprehensive information.
• Obtain an orthodontic opinion before arranging treatment under a general anaesthetic.
• Treatment plans should take into account child compliance (117).
• Avoid extracting permanent teeth until co-operation and oral hygiene are adequate.

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Oral Health Education and Promotion
• Oral health education programmes should be developed that address the needs of individuals and carers (personal or professional).
• Advice should be given on the effects of smoking, abuse of alcohol, general substance abuse, and if appropriate, these issues should be highlighted with carers and parents.

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Professional Oral Health Care
• Contact should be maintained with the same dental practitioner wherever possible.
• Preparation for transition should be made one year in advance and introductory visits bbarranged to the new dentist if appropriate.
• Referral schemes should be developed to enable continuing oral care.
• Everybody should have a clear policy on oral hygiene with established links to local dental services.
• Oral health should be part of the individual healthcare plan.
• Educational institutions should include oral health as part of training or socialisation programmes.

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Dietary Advice
• Dietary advice for all people with learning disabilities should be made within the context of healthy eating policies (131)
• Carers and health professionals should be provided with training to promote healthy eating and its effect on oral health (131).
• Policies should be developed to ensure referral to and advice from the dental team to instigate appropriate prevention techniques.

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Oral Health Education
• Oral health education should be provided for all and tailored to individual needs.
• All carers (family or professional) providing care or support for individuals unable to care adequately for themselves should be given advice in oral health education(8).
• Oral care to be provided at home for people with learning disabilities should be documented in individual oral care plans.
• Standards for oral care should be part of operational strategies in individual residential homes.

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Oral Assessment and Care Planning
• Everyone should have a regular oral assessment.
• The frequency of oral assessment should be related to the individual’s needs.
• Carers should be encouraged to obtain an oral health assessment for their client.
• An annual assessment should be carried out for people who are edentate.
• Assessment should be more frequent for those with multiple disabilities, those on sugar- based medication or sugar-based dietary supplements and other risk factors for oral health.
• Oral care should be an integral part of social care planning and should be included in national, local and residence based learning disability strategies(21).

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Individual Oral Care Plans
• A written care plan should follow individual assessment.
• Oral care plans should include a record of professional care to be provided by the professional and the daily oral care to be provided at home.
• Oral care plans should be part of Health Care plans.

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Treatment and Care
• Treatment and care should be offered based on the needs of the individual (37,41,47).
• Frequency of appointments should be determined by the need for acclimatisation.
• Treatment and care for adults unable to give informed consent should be discussed with family, carers or advocates.
• Protocols for oral care should be developed for adults who are unable to make decisions and give consent for their treatment and care (41,47,138).
• Secondary services and in particular general anaesthesia and sedation services should be available locally.
• Waiting times for treatment should be comparable to those for the general population.
• Emergency care for people with learning disabilities should be available on the same basis as the general population.
• Treatment and care should be provided in an empathetic and knowledgeable environment.
• Oral care and treatment should be provided on a flexible basis dependent on the personal circumstances of the patient e.g. domiciliary care provision and using mobile facilities.

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Referral and Discharge
• Effective referral mechanisms should be developed to encourage multidisciplinary referral of people with learning disabilities to oral health care services.
• Effective referral mechanisms should be developed for adults leaving hospital and for those moving between residential homes.

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Older People:
• Oral health care services should be similar to those available to the general population.
• Oral care for older people with learning disabilities should take into account the difficulties and barriers posed by both advancing age and learning disability (8).

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People with Medium and High Support Needs
• Primary dental care services should continue to be developed for all adults with learning disabilities.
• Services should be provided in general dental practice for those who are more independent.
• Services should be provided in the Community Dental Service for those with higher levels of dependency.
• Health Authorities should include oral health care specifications for people with learning disabilities in Health Improvement Plans.

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• The oral healthcare team should know and record details of the patient’s preferred method of communicating.
• Appropriate language must be used.
• Speech should be slow and clear.
• The patient should be spoken to directly, using the name they prefer.
• The Oral Health Care Team should be trained in basic signing and communication skills.
• The patient should be given plenty of time to respond.

C>

Drooling
• A multi-disciplinary team should make an individual assessment (141).
• Techniques designed to improve posture should be implemented (141).
• Treatment should be started with non-pharmacological and non-surgical methods (141).
• There should be careful monitoring for oral complications if surgical or pharmacological treatment is carried out (140) .

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Bruxism
• Construction of splints may be helpful but its success is dependent on patient compliance.
• An opinion should be sought from an appropriate dental specialist if required.

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Erosion
• Patients should be advised to use fluoride mouthrinses.
• Toothpaste low in abrasion and high in fluoride should be used regularly (144) (not for children below 6 years).
• Professional application of fluoride varnish is advised. (143,144)
• Dentine bonding agents may be of value (143) in the treatment of patients with erosion.
• An opinion should be sought from an appropriate dental specialist if required.

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Dry Mouth
• Saliva replacements may be useful.
• The use of sugar-free chewing gum and sugar- free fluids should be advised.
• The mouth should be examined frequently.
• Fluoride rinses should be considered to reduce risk of dental caries.
• An opinion should be sought from an appropriate dental specialist if required.

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Self Injurious Behaviour
• All dental causes should be eliminated (148).
• Construction of mouthguards or other oral appliances should be considered.
• Distraction and behavioural psychology is a useful management option.

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Feeding Problems
• Individual assessment should be carried out.
• Good oral hygiene should be promoted.
• An intensive regimen should be followed to prevent oral disease.
• Dentist and family doctor should be consulted for advice.

• Each person should be assessed individually
• Appropriate facilities should be available(115).
• The dental team should have training in the use of sedation for dentistry.(115).

• The appropriate resources and facilities for general anaesthetics should be available locally to treat people with learning disabilities (115).
• General anaesthesia should be the last choice for treatment (115).
• Collaborative work should be undertaken with professional colleagues to minimise the number of general anaesthetics required.

Grading of Recommendations