Clinical Guidelines & Integrated Care Pathways For The Oral Health Care Of People With Learning Disabilities

Extract taken from www.rcseng.ac.uk

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).

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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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Integrated Care for the Pre School and School Age Child
* Information on access to available services should be circulated to parents, carers and health.-care professionals.
* Early referral to the dentist should be encouraged from child development teams and bbconsultant paediatricians (107).
* Health care professionals and carers should be advised of the alternative ways in which oral healthcare can be delivered e.g. home visits, mobile dental units, in special schools in addition to a dental practice.
* Professionals should collaborate to identify children with learning disabilities in mainstream and special education centres and refer to the appropriate oral healthcare services (107).

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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.

3.2 The Transition Stage

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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.

3.3 Adults and Older People

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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.

3.4 Communicating with People who have Learning Disabilities

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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.

3.5. Management of Specific Complications

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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.

3.6 Use of Sedation for People with Learning Disabilities
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* 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).

3.7. Use of General Anaesthesia for People with Learning Disabilities
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* 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.

Levels of Evidence
LevelType of Evidence
IaEvidence obtained from meta-analysis or randomised control trials
IbEvidence from at least one randomised control trial
IIaEvidence obtained from at least one well designed control study without randomisation
IIbEvidence obtained from at least one other type of well designed quasi-experimental study
IIIEvidence obtained from well designed non-experimental descriptive studies, such as
comparative studies, correlation studies and case control studies
IVEvidence from expert committee reports or opinions and/or clinical experience of
respected authorities

Grading of Recommendations

GradeRecommendations
A> (Evidence levels Ia, Ib)Requires at least one randomised controlled trial as part of trhe body of literature of overall good quality and consistency addressing the specific recommendations.
B> (Evidence levels IIa, IIB, III)Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
C> (Evidence level IV)Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates abscence of directly applicable studies of good quality.
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