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

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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Initial Visit
* An oral health care plan should be agreed with the 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 cooperation 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).
* The 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 the 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.

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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 mouth rinses.
* 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 the 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