Special Needs
Dental Disease Prevention and People With Special Needs
Paul Glassman, DDS, MA, MBA, and Christine Miller, RDH, MSH, MA
Paul Glassman, DDS, MA, MBA, is professor of dental practice and community
services, associate dean for information and educational technology, director
of the Advanced Education in General Dentistry Program, and co-director
of the Center for Oral Health for People With Special Needs at the University
of the Pacific School of Dentistry.
Christine Miller, RDH, MSH, MA, is associate professor of dental
practice and community services, director of community programs, and co-director
of the Center for Oral Health for People With Special Needs at UOP School
of Dentistry.
Copyright 2003 Journal of the California Dental Association.
 |
People with special needs are the most underserved of the underserved in our society. They have more dental disease, more missing teeth, and more difficulty obtaining dental care than other segments of the population. Many individuals and groups, including the authors of this paper, have developed community-based systems to improve oral health for people with special needs. However, these systems have not been as successful as they might be because of lack of effective preventive protocols specifically designed for people with special needs. This paper reviews strategies for overcoming informational, physical, and behavioral barriers to oral health and presents a summary of the results of a conference titled "Practical Preventive Protocols for Prevention of Dental Disease in People with Special Needs in Community Settings." The rationale for using an Oral Health Care Plan is presented as well as a sample plan. These strategies and protocols are designed to complement the system of supported community-based oral health care. The goal of this system is to help people with special needs enjoy a lifetime of oral health the same as other members of our society.
|
People with special needs are the most underserved of the underserved in our society. They have more dental disease, more missing teeth, and more difficulty obtaining dental care than other segments of the population.1-6 Not only is access to dental services difficult, but treatment can be more difficult when services are obtained. Often there is inadequate attention to preventing dental disease in these populations. The combination of inadequate attention to prevention, greater disease burden, scarce treatment resources, and more difficulty in performing treatment results in pain, suffering, and social stigma in these populations beyond that found in other segments of our society.
Reports that focus on people with developmental disabilities residing in community settings have shown that these individuals have significant unmet medical needs in general,7-10 as well as significant unmet dental needs.11-14 The situation is even worse for individuals with disabilities who are living in rural areas of our country.15 The Surgeon General’s Report on Oral Health points out that populations with mental retardation or other developmental disabilities have significantly higher rates of poor oral hygiene and an increased need for periodontal treatment than the general population. In addition, people with disabilities have a higher rate of dental caries than the general population and almost two-thirds of community-based residential facilities report that inadequate access to dental care is a significant issue.16-19 Untreated dental disease has been found in at least 25 percent of those with cerebral palsy, as well as 30 percent of those with head injuries, and 17 percent of those with hearing impairment.2 A study commissioned by the Special Olympics concluded that the oral health of individuals with mental retardation is poorer than that of their peers without mental retardation. Individuals with mental retardation have more untreated caries and a higher prevalence of gingivitis and other periodontal diseases than those in the general population.20
People with special needs residing in community residential facilities are dependent upon community-based sources of dental preventive and treatment services in greater numbers than ever before. In the mid 1970s and since, as a part of the de-institutionalization and normalization process, almost two-thirds of those individuals residing in institutional settings were moved into community-based settings. Unfortunately, the dental care services received in institutions are often unavailable once these individuals are moved into the community.21 Therefore, de-institutionalization has exacerbated the problem that many individuals with special needs have in obtaining access to dental care as they move from childhood to adulthood. Availability of dental providers trained to serve special needs populations and limited third-party support for the delivery of complex services further complicate the issues entailed in addressing the needs of these populations.1 There are even some that believe that the health care system in the United States practices active discrimination against people with disabilities for no other reason than because they have a disability that makes the health care professional uncomfortable.22
People with developmental disabilities are served in California by a network of private agencies referred to as Regional Centers. These centers contract with the California Department of Developmental Services to provide a local resource to help find and access the many services available to individuals with developmental disabilities and their families. Individuals with developmental disabilities are referred to as "consumers" of the Regional Center services. In 1998, working with the Department of Developmental Services, the University of the Pacific School of Dentistry took a leadership role in starting a Statewide Task Force on Oral Health for People With Special Needs. This task force has brought together diverse dental and social service organizations and individuals to foster communication, collaboration, and advocacy to improve oral health for people with special needs. One activity of this task force was the 1999 assessment of needs and resources for people with developmental disabilities in California.23 Data was collected through surveys of 139 staff members from 14 Regional Centers serving 89,000 consumers, a sample of 538 consumer surveys and oral health screenings, and surveys of 320 dental professionals. Among the many findings was the fact that there were inadequate resources in the Regional Center system for identifying oral health problems, making referrals, or tracking treatment outcomes. There were few organized preventive education programs. Consumers reported multiple problems finding dentists willing to treat them and accessing the limited services that were available. Oral health screenings revealed that 80 percent of those screened had current dental disease and yet 60 percent reported that they were unaware of any dental problems. Finally, the dental professionals surveyed reported that they did not feel that they were adequately trained to provide the care needed by this population. These findings are consistent with those reported above, again demonstrating the mix of ubiquitous dental disease, inadequate treatment resources, and the absence of an organized prevention system.
People with special needs who are having difficulty obtaining treatment and preventive dental services also include the nation’s growing frail senior citizen population. An estimated 70 percent of the nation’s 2 million plus nursing home population has dental problems that include dentures that don’t fit and loss of some or all of their teeth, but most significantly poor oral hygiene.2
People with special needs or their caregivers may have limitations in the understanding of and physical ability to perform personal prevention practices or to obtain needed services.1 Some oral problems are exacerbated by associated medical problems or the side effects of medication, or caused by the disability itself.
Many individuals and groups, including the authors of this paper, have developed community-based systems to improve oral health for people with special needs.11,24-31 The programs developed by the authors have included activities to build community coalitions, develop triage and referral systems, train community oral health professionals, develop sources of outpatient and hospital dental services, and develop and implement community-based prevention programs. They have used the services of a dental coordinator, typically a dental hygienist, who has acted as a "dental case manager" and liaison between community social service agencies and local oral health professionals.
As a part of the community-based system just described, the authors have developed prevention training materials and demonstrated their effectiveness in improving caregiver knowledge and participation in prevention practices. They have also demonstrated the effectiveness of these materials in teaching dental and dental hygiene students about considerations for improving the oral health of special needs populations.32-34 These materials -- which include a videotape, workbook, and trainers manual -- incorporate information about oral health and disease, oral hygiene practices, and behavioral interventions. There is an emphasis on developing an individual oral health plan for each individual. There is, in addition, information about the use of chemotherapeutic agents as part of an oral hygiene regimen. However, at the time that those recommendations were developed there were not clear, practical protocols available in the literature that were agreed upon by groups of experts and that could be applied in community settings. Also, many of the new preventive strategies depend upon the ability of the individual to be evaluated and treated in a dental office or to cooperate for certain professionally applied therapies. This is not always possible for people with special needs.
The lack of practical protocols for the prevention of dental diseases in community settings, along with limited reimbursement for these preventive practices and regulatory barriers to their use, was the major motivation for a conference.
The Conference
The conference titled "Practical Preventive Protocols for Prevention of Dental Disease in People With Special Needs in Community Settings" was held in February of 2002 at the University of the Pacific School of Dentistry. This conference was supported by a grant from the state Department of Developmental Services Wellness Program and administered through the Redwood Coast Regional Center. Expert panelists were invited to review the literature and present information on various preventive protocols. Table 1 lists the experts and their topic areas. There was also a panel of reactors, listed in Table 2 who commented on the expert panel presentations and participated in the development of the protocols.
The premise for the conference was that regular professional oral health care, plaque and diet control, fluoridated water supplies, and professionally applied sealants are all widely accepted measures to prevent dental diseases.1,35 Other methods of preventing dental disease are less widely used or accepted. Although there have been several decades of research on the use of chemotherapeutic agents, they are not widely used in the practice of dentistry.1 A number of these interventions could be used in community settings and may not require the use of a dental office setting. One of the reasons that these measures are not used more broadly is the lack of practical protocols for their use, particularly in community settings. It is clear that confining treatment and prevention modalities to use in dental offices will not be effective with populations of people with special needs who have difficulty accessing dental office treatment. Therefore, it was believed to be critical to develop interventions that do not require a dental office setting.
The complete results and background papers for the conference described above will be published elsewhere, but the major findings are summarized in the recommendations listed below. The recommendations described here also include guidelines included in the preventive training package called Overcoming Obstacles to Dental Health: A Training Program for Caregivers of People With Special Needs.36
The conference described above and this paper use the term "people with special needs" to describe people who have difficulty accessing dental treatment services because of complicated medical, physical, social, or psychological situations. The broad category of "people with special needs" encompasses a wide variety of individuals with different abilities and living situations. The emphasis is on individuals who may have trouble fully following traditional oral health recommendations for control of plaque, who may not be able to rinse and spit out oral solutions, and who may need assistance carrying out preventive recommendations.
The focus of the recommendations contained here is on measures that can be applied in "community" settings including individual and family homes, residential care facilities, day work and treatment centers, skilled nursing facilities, hospitals, and other settings outside of a dental office or clinic. The focus on community settings is considered essential because effective long-term prevention must take place primarily outside of dental offices or clinics, and many people with special needs have difficulty accessing dental offices or clinics.
Prevention Recommendations for People With Special Needs
Overcoming Barriers
Barriers to prevention of dental disease for people with special needs can be classified into three types: informational, physical, and behavioral.36 As described in the Overcoming Obstacles to Dental Health training materials, informational barriers include a lack of understanding among individuals and their caregivers about effective practices to prevent dental disease. Since people with special needs can be dependent upon someone else, a caregiver, to help them carry out preventive practices, it is critical that both the individual and his or her caregiver understand the causes and techniques for prevention of dental disease. It is not likely that a caregiver will do more for the individual they are caring for than they will do for themselves. Therefore caregivers must understand the importance and benefits of oral preventive practices as well as the techniques to accomplish them. Whether the caregiver is a direct-care staff member in a community residential care facility, a licensed vocational nurse in a nursing home, or a parent of a child living at home, he or she can be motivated by the knowledge that good oral health is a part of good general health, that good oral health can make an individual more independent in other areas of their lives, and that maintaining good oral health can make the life of the caregiver more pleasant as well as the life of the individual he or she is caring for. Dental professionals can have an important role in passing on this information in dental office settings, community preventive presentations, and in-services in institutional care settings. Specific information about application of chemotherapeutic interventions will be addressed in the section on the medical model below.
Another barrier to prevention of dental disease is physical. Some people have the understanding about what needs to be done, but lack the musculature, dexterity, or coordination to do it. There are numerous adaptations and aids that can help overcome these physical barriers. Figure 1 shows toothbrushes that have been adapted with a larger handle using a tennis ball or bicycle handle grip. Figure 2 shows someone with limited dexterity using a large foam ball as a means of picking up a toothbrush. Similar adaptation can be made for floss holders.
A general principle in working with people with special needs is that they should be encouraged to do as much as possible for themselves. However, if they have limited ability to perform oral hygiene procedures, they may need help from a caregiver to complete those procedures. This is referred to as "partial participation." There are several positioning techniques that can make it easier for a caregiver to help someone complete oral hygiene procedures. Figure 3 is an illustration of a "tongue blade mouth prop." This type of mouth prop can be easily constructed by a caregiver from readily available materials and can be very useful in helping someone complete oral hygiene procedures. Figure 4 shows the use of a tongue blade mouth prop with someone who is sitting on the floor with their head resting on the caregiver’s shoulders. Note the use of the forefingers of the left and right hand in stabilizing the head. Figure 5 again shows the use of a tongue blade moth prop. This time the individual may be less able to help and is positioned on a couch. Note the use of the right forearm and the tongue blade in stabilizing the head. These positions allow the caregiver to see and gain access to parts of the mouth that would be difficult in other positions. Again, dental professionals can play a pivotal role in educating caregivers about the use of physical adaptations and partial participation.
Finally, there are behavioral obstacles to preventing dental disease. People can be resistant to performing oral hygiene practices for a variety of reasons. Behavioral obstacles can be overcome using one of several behavioral intervention techniques. These techniques include:
n Structuring the environment: This refers to picking a place or time of day that is more conducive to gaining cooperation than other times or places. It may be a place or time that reduces distractions, removes unpleasant associations to oral hygiene procedures, or makes oral hygiene procedures seem fun.
n Involving the individual: People with special needs, especially in group living or institutional living arrangements, may have very regimented lives. They may be told when to wake up, when to eat, when to use the bathroom, what to wear, and what they will do during the day. Anything that a caregiver can do to increase choices can aid cooperation. This can be a simple as being able to choose when to brush one’s teeth or what color a new toothbrush will be. It also involves paying attention to how someone is doing and not pushing them so far so that a pleasant oral hygiene session turns into an unpleasant one.
n Using reinforcers: We all respond to things that are rewarding to us by wanting to continue or increase the activity that produced the reward. Carefully applied rewards can motivate people to become more and more independent in oral hygiene practices. It is important to use things that are actually rewarding for the individual and to monitor the effect of the reward over time and change it if necessary. Caregivers can be educated to realize that social rewards like smiling and praise can be as powerful for people with special needs as they can for everyone else.
n Shaping: Shaping is the reinforcement of an approximation of the task. If you would like someone to brush for five minutes, you might use a reinforcer after 30 seconds at first. Later the reinforcer might not be used until one or two minutes have passed. It is also critical to make sure that each session is a pleasant one and ends with the individual having a good feeling about themselves and their oral health.
Dental professionals can have an important role in educating caregivers about behavioral interventions. More information about the techniques described above can be found in the Overcoming Obstacles to Dental Health training materials.36
The Medical Model
The use of chemotherapeutic agents to prevent dental disease has been referred to as the medical model of dental prevention and is reviewed in other articles in this Journal and the issue to follow. These agents may need to be used differently with people with special needs than with other individuals. As described above, these differences are the results of the need to have protocols that can be used with people who may have trouble fully following traditional oral health recommendations for control of plaque, who may not be able to rinse and spit out oral solutions, and who may need assistance from third parties in carrying out preventive recommendations. In addition, protocols for use with special needs populations must be able to be applied outside of the dental office in community settings.
The expert panelists who were part of the conference titled "Practical Preventive Protocols for Prevention of Dental Disease in People With Special Needs in Community Settings" described above developed the following recommendations:
n People with special needs should follow certain traditional and widely accepted preventive measures as much as possible for that individual. These fundamental practices include:
n Use of a fluoridated toothpaste accepted by the Council on Dental Therapeutics of the American Dental Association. After the age of 12, or when a dental professional finds that gingivitis is present in an individual younger than 12, use a fluoridated toothpaste accepted by the American Dental Association Council on Dental Therapeutics that contains an approved effective antigingivitis agent;
n Effective removal of bacterial plaque using a soft manual or mechanical toothbrush and dental floss;
n Daily use of fluoridated water for drinking and cooking. This may require the use of bottled fluoridated water where the community water supply is not optimally or adequately fluoridated;
n Adopting a healthy diet with an emphasis on reduction of fermentable carbohydrates intake, especially between meals;
n Regular professional oral health care including the use of professionally applied topical fluorides and pit and fissure sealants; and
n Controlling systemic factors
that may affect oral health such as cessation and prevention of smoking
and use of tobacco products and adequate treatment of systemic diseases
that affect oral health such as diabetes.
n Use products containing xylitol
(at least 50 percent by weight) as the predominant sugar with three exposures
per day and five minutes per exposure. If xylitol-containing chewing gum
can be used, it should be chewed for five minutes three times a day. Chewing
may need to be supervised to ensure that the required exposure is achieved.
For individuals who cannot chew gum, or where supervised gum chewing is
not feasible, other xylitol-containing food products should be substituted.
For infants, there are delivery systems that use pacifiers with a xylitol
reservoir where a xylitol solution can be placed or traditional baby bottles
with xylitol containing solutions. For other individuals, dissolving a
xylitol-containing lozenge, mint, or lollipop can achieve the desired
exposure.
n Apply fluoride varnish using
one of the following regimens. The panel recognizes that the use of fluoride
varnish requires some removal of food debris by brushing or wiping off
the teeth prior to application. There may be some individuals or circumstances
where this is not possible. The selection of the regimen should be based
on the feasibility of following that regimen for a given individual.
n Apply fluoride varnish three times in one week (e.g. Monday, Wednesday, and Friday), once per year.
n Or, apply fluoride varnish once
every six months.
n For individuals who are not able
to fully use the primary preventive interventions described above or for
those with persistent decay in spite of the above therapies, fluoride-containing
rinses can be of benefit to prevent dental caries. Even if individuals
are able to fully use the three primary preventive interventions described
above, fluoride-containing rinses may provide an additional source of
topical fluoride. Fluoride mouthrinse is currently an optional preventive
choice for all people older than 6 who can safely rinse and expectorate
without ingestion. Fluoride of 0.05 percent NaF2 has proven
anticaries effects, and these effects are additive to the use of fluoride-containing
toothpaste. Use a fluoride rinse product that contains 230 ppm fluoride
without alcohol. Rinse for one minute twice a day.
If an individual cannot rinse or spit out the solution, then apply
the solution with a cotton swab or sponge applicator (Toothette) twice
a day. Although the available evidence has not proven that there is an
additive effect when 0.05 percent NaF2 fluoride rinse is used
with a fluoride varnish, such an effect has been demonstrated when used
in conjunction with fluoridated toothpaste. A dental professional should
be involved in the decision to add fluoride rinses as an intervention
for a particular individual if the individual is younger than 6 and/or
is unable to rinse without ingestion.
n The use of high-concentration
fluoride toothpaste or gel should be considered for individuals where
the previous recommendations are not working to adequately prevent dental
caries or there is reason to believe that they will not work. One such
circumstance could be an individual with xerostomia (dry mouth) resulting
from medications, radiation treatment that involves the salivary glands,
or other causes. The decision to use these products should also consider
the ability of the individual or caregivers to supervise and control the
application of these products since they contain concentrations of fluoride
that could be toxic if sufficient quantities are ingested. Typically these
products contain 5,000 ppm of fluoride; and the recommendation is to brush
with the toothpaste or gel before going to sleep at night, spit out the
excess, and leave the residual toothpaste or gel on the teeth while sleeping.
Water should not be used to rinse out the excess nor should water be consumed
for one hour after use of the gel or toothpaste.
Because of the considerations just listed, a dentist should be involved
in the decision to add high-concentration fluoride toothpaste or gel as
an intervention for a particular individual.
n For individuals who are not able
to fully use the primary preventive interventions described above or for
those with persistent decay in spite of those therapies, using a chlorhexidine
rinse can be of benefit to help prevent dental caries. Rinse with a half-ounce
of chlorhexidine solution for one minute twice a day for two weeks. Repeat
this four times a year.
If an individual cannot rinse or spit out the solution, then apply
the solution with a cotton swab or sponge applicator (Toothette) twice
a day. Because it is not clear that there is added benefit from this procedure
for individuals who are able to use the primary protocols listed here,
a dentist should be involved in the decision to add chlorhexidine rinses
as an intervention for a particular individual.
Since chlorhexidine is more effective at reducing levels of caries-producing
microorganisms than is xylitol, for some individuals an initial course
of chlorhexidine may be indicated prior to instituting a long-term regimen
of xylitol exposure.
It should be remembered that chlorhexidine has several side effects, including diminution of taste and staining of oral tissues, that make it less desirable than some of the other agents described above, especially for individuals who may need long-term therapy.
The Oral Health Care Plan
Many people with special needs, particularly those in group and institutional living situations, have numerous caregivers who may be helping them maintain oral health. It is critical that these caregivers understand the strategy being employed for that individual and coordinate their efforts. It is also helpful, even when the caregiver is a parent of an individual living in a family home, to have a specific plan for maintaining oral health. Figure 6 is an example of such a plan.32
There are several advantages to using a planning and communication document such as the one in Figure 6. First, it serves to help caregivers organize their thinking about the treatment and preventive measures that are to be used for a particular individual. It helps them to think about specific interventions and measures that address the specific needs of that individual. Second, it acts as a communication vehicle so multiple caregivers can be kept up to date about the current strategies being used. Finally, it acts as a record of progress. If it is periodically updated, then caregivers can look back at old plans to review progress and use the sections of the current plan that act as reminders of future appointments or interventions.
Summary
People with special needs have the most dental disease and the least access to treatment services of any segment of our population. Therefore, it is critical that everything possible be done to prevent the occurrence of dental disease in these individuals. This article has reviewed strategies for overcoming informational, physical, and behavioral barriers to maintaining oral health. In addition, a summary has been provided of the results of a conference titled "Practical Preventive Protocols for Prevention of Dental Disease in People With Special Needs in Community Settings." These strategies and protocols are designed to complement a system of supported community-based oral health care. The goal of this system is to help people with special needs enjoy a lifetime of oral health the same as other members of our society.
References
1. US Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
2. The Disparity Cavity: Filling America’s Oral Health Gap. Oral Health America, May 2000.
3. Haavio ML, Oral health care of the mentally retarded and other persons with disabilities in the Nordic countries: Present situation and plans for the future. Spec Care Dent 15:65-69, 1995.
4. Feldman CA, Giniger M, et al, Special Olympics, Special Smiles: Assessing the feasibility of epidemiologic data collection. J Am Dent Assoc 128:1687-96, 1997.
5. Waldman HB, Perlman SP, Swerdloff M, Use of pediatric dental services in the 1990s: Some continuing difficulties. J Dent Child 67:59-63, 2000.
6. Oral Health: Factors Contributing to Low Use of Dental Services by Low-Income Populations. United States General Accounting Office. Report to Congressional Requesters. Sept 2000.
7. Minihan PM, Dean DH, Meeting the needs for health services of persons with mental retardation living in the community. Am J Public Health 80:1043-8, 1990.
8. Schor EL, Smalky KA, Neff JM, Primary care of previously institutionalized retarded children. Pediatrics 67:536-40, 1981.
9. McDonald EP, Medical needs of severely developmentally disabled persons residing in the community. Am J Ment Defic 90:171-6, 1985.
10. Ziring PR, Kastner T, et al, Provision of health care for persons with developmental disabilities living in the community. J Am Med Assoc 260:1439-44, 1988.
11. Dane JN, The Missouri Elks Mobile Dental Program -- dental care for developmentally disabled persons. J Public Health Dent 50:42-7, 1990.
12. Preest M, Gelber S, Dental health and treatment of a group of physically handicapped adults. Community Health 9:29-34, 1977.
13. Ferguson FS, Kamen P, et al, Dental fellowships in developmental disabilities help broaden care of the disabled. NY State Dent J 58(9):55-8, 1992.
14. Wilson KI, Treatment accessibility for physically and mentally handicapped people -- a review of the literature. Comm Dent Health 9:187-92, 1992.
15. Hill EG, Health Care in Rural California: the 1990-91 budget. from Perspectives and Issues, Reports of the Legislative Analyst. Legislative Analyst’s Office, Sacramento, Calif, 1990.
16. Beck JD, Hunter RJ, Oral health status in the United States: problems of special patients. J Dent Educ 149:407-25, 1985.
17. White BA, Caplan DJ, Weintraub JA, A quarter century of changes in oral health in the United States. J Dent Educ 59(1):19-60, 1995.
18. Waldman HB, Perlman SP, Swerdloff M, What if dentists did not treat people with disabilities? J Dent Child 65:96-101, 1998.
19. Dwyer, Northern Wisconsin Center for the Developmentally Disabled unpublished data, 1996.
20. Horwitz S, Kerker B, et al, The Health Status and Needs of Individuals With Mental Retardation. Special Olympics, 2000.
21. Thornton JB, al-Zahid S, et al, Oral hygiene levels and periodontal disease prevalence among residents with mental retardation at various residential settings. Spec Care Dentist 9(6):186-90, 1989.
22. Schriver T, Testimony before a Special Hearing of a Subcommittee of the Committee on Appropriations of the United States Senate 107th Congress, First Session. Anchorage, Alaska. March 5, 2001.
23. Glassman P, Miller CE, A Statewide Assessment of Oral Health Status and Resources for People with Developmental Disabilities. Fall 1999. Unpublished data.
24. Glassman P, Miller CE, Improving Oral Health for People With Special Needs Through Community-Based Dental Care Delivery Systems. J Cal Dent Assoc 16(5):404-9, 1988.
25. Glassman P, Miller C, Lechowick J, A dental school’s role in developing a rural, community-based dental care delivery system for individuals with developmental disabilities. Spec Care Dent 16(5):188-93, 1996.
26. Capilouto E, Access to appropriate dental care. Curr Opin Dent 1(3):316-21, 1991.
27. Nielsen-Thompson N, Access problems and solutions: ramifications for dental hygiene research. Dental Hygiene 1:34-7, 1988.
28. Gotowka TD, Johnson SJ, Gotowka CJ, Costs of providing dental services to adult mentally retarded: a preliminary report. Am J Public Health 11:1246-50, 1982.
29. Gibson GB, Swanson AE, Developing an undergraduate hospital dentistry program. J Dent Educ 55(11):738-42, 1991.
30. Burtner AP, Dicks JL, Providing oral health care to individuals with severe disabilities residing in the community: Alternative care delivery systems. Spec Care Dent 14(5):188-93, 1994.
31. Helgeson MJ, Smith BJ, et al, Frail Elderly Adults. Dental Care Considerations of Disadvantages and Special Care Populations: Proceedings of the Conference Held April 18-19, 2001, in Baltimore, Md. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine and Dentistry, Division of Nursing, April 2001.
32. Miller C, Glassman P, et al, Overcoming Obstacles to Dental Health -- A Training Program for Caregivers of People With Disabilities, 4th ed. A training package consisting of a videotape, workbook, trainers manual, and pre- and post-tests, 1998.
33. Glassman P, Miller C, et al, A preventive dentistry training program for persons with disabilities residing in community residential facilities. Spec Care Dent 14(4):137-43, 1994.
34. Miller C, Glassman P, Beyond brushing: training dental students to assess and create oral health plans for people with disabilities. J Dent Ed 59(2):133 (abstract), 1995.
35. Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries: A Report on Recommendations of the Task Force on Community Preventive Services. MMWR 50(RR21):1-13, 2001.
To request a printed copy of this article, please contact: Paul Glassman DDS, MA, MBA, UOP School of Dentistry, 2155 Webster St., San Francisco, CA 94115, or pglassman@sf.uop.edu.
Legends
Figure 1. Toothbrushes adapted for easier grip (Copyright UOP School of Dentistry. Reprinted with permission).
Figure 2. Adapted toothbrush for someone with limited dexterity (Copyright UOP School of Dentistry. Reprinted with permission).
Figure 3. A tongue blade mouth prop (Copyright UOP School of Dentistry. Reprinted with permission).
Figure 4. Partial participation -- using positioning and a tongue blade mouth prop (Copyright UOP School of Dentistry. Reprinted with permission).
Figure 5. Partial participation -- using positioning and a tongue blade mouth prop (Copyright UOP School of Dentistry. Reprinted with permission).
Table 3. The Oral Health Care Plan.
