Poor oral hygiene is a problem for many people with mental retardation who live in state residential facilities. An integrated treatment approach to improve oral hygiene was designed and implemented. The program focused on increasing cooperation with daily oral care. We examined whether individualized oral care plans were more effective in improving the oral hygiene of people living in this facility than generalized staff training in oral care procedures. Oral hygiene ratings of 80 individuals were tracked over a one-year period and analyzed. A modest improvement was found for all people studied, with a greater improvement for those with individualized oral care plans. The need for follow-up data and procedures to ensure follow through of recommendations is emphasized.
Oral hygiene has been a long-standing concern for individuals with mental retardation. Although the delivery of dental services to people with special needs has improved over the years, the status of their oral health has remained essentially unchanged (Jurek & Reid, 1994). Jurek and Reid examined the results of clinical surveys taken 10 years apart (1980 and 1990) and reported that although there were fewer people with conditions requiring restoration (81%) and extraction (45%), the need for prophylaxis and incidence of periodontal disease increased between 14% and 18%. In addition, the average plaque accumulation on teeth was measured to be just below 70% of the total surface area for both surveys. With poor oral hygiene being recently associated with several other health problems, including risk for heart disease (Scully, Roberts, & Shotts, 2001), the need to improve oral hygiene among people with mental retardation has become increasingly important.
This trend of continued difficulties with oral hygiene, despite improved dental services, was consistently found among other individuals who live in residential facilities (Whyman, Treasure, Brown, & McFayden, 1995). Greene Valley Developmental Center—GVDC (Greeneville, TN) currently serves approximately 350 people with varying degrees of mental retardation, although the majority of individuals (approximately 320) are functioning in either the severe or profound range. Those with mild or moderate mental retardation have either significant medical or behavioral difficulties that currently keep them from community placement. Review of dental records indicated that as of September 1998, approximately 150 individuals (38%) of those residing at the facility had an oral hygiene rating by the staff dentist or hygienist of poor or very poor. Although a variety of reasons were offered for this high percentage (medications, physical conditions, diet, dysphagia), a survey indicated that the greatest factor contributing to this condition was the person's resistance to dental and oral care procedures. Consequentially, the Behavioral Medicine Interdisciplinary Workgroup was formed to help people living at GVDC to become more comfortable and cooperative with daily oral care procedures.
Workgroup membership spanned a wide array of disciplines, including psychology, dentistry, occupational therapy, speech language pathology, medicine, physical therapy, nursing, case management, rights advocacy, staff development, direct support staff, and direct support staff supervision. The group met weekly for a period of 18 months. After meeting for 6 months, 39% of individuals still had oral hygiene ratings of poor or very poor.
Daily oral care needed to be done in the person's living area. Several investigators have found that regular oral care with an electric toothbrush significantly improves oral hygiene among individuals with mental retardation (Bratel & Berggren, 1991; Carr, Sterling, & Bauchmoyer, 1997). However, most individuals at GVDC resisted using electric toothbrushes; many others would not allow tooth brushing even with a manual toothbrush. As most individuals living at the facility had severe and profound adaptive and intellectual deficits and required staff assistance with daily oral care, the group decided to focus on well-defined interventions to help individuals develop improved tolerance to daily oral care. In this article we examine the effectiveness of individualized oral care plans in improving the delivery of oral care as measured by ratings of oral hygiene over time. We hypothesized that people participating in individualized oral care plans would show greater improvement in oral hygiene than would a nontreatment control group.
Participants were individuals living at GVDC who received a minimum of three oral hygiene ratings from the Dental Department between March 1999 and March 2000. A total of 79 people (44 men, 35 women between the ages of 22 and 57 years) were included in the results. Twenty-four individuals (30%) were within the mild–moderate range of mental retardation, and the remaining 55 (70%) were in the severe to profound range.
Each participant received an oral hygiene rating by either the GVDC dentist or dental hygienist every 3 to 4 months. According to the personnel in the Dental Department, ratings were based on the level of plaque formation on the teeth, with greater plaque formation leading to a poorer rating. Ratings were defined as follows: (a) excellent: no plaque present on teeth; (b) good: plaque present on less than 15% of total tooth surface. (c) fair: plaque present on 15% to 50% of total surface. (d) poor: plaque present on 50% to 90% of total surface. (e) very poor: plaque present on greater than 90% of total surface.
There was not a standardized measurement of plaque accumulation, but interrater reliability for the two raters was 85%. Interrater reliability was evaluated by having both raters independently rate the same 20 individuals. The distribution of ratings across the entire facility (N = 341) resembled a normal curve, with the most frequent rating given being fair (42%) followed by poor (22%), good (20%), very poor (15%), and excellent (1%). For the purposes of this study, we derived individual ratings by their current oral hygiene status as of March 20, 1999, and March 20, 2000.
Participants were randomly separated into two groups: the treatment group (received intervention through an individualized oral care plan—see Appendix A) and the no treatment group, who did not receive any direct intervention, although staff members who worked with individuals in this group were trained on general oral care strategies (see Appendix B). People in both groups were recommended for individualized oral care plans by the person's interdisciplinary team due to multiple ratings of poor oral hygiene within 12 months prior to March 20, 1999. Individuals were selected for each group based on the timeliness of their referral, with the earlier referrals receiving the individualized oral care plans and the remaining individuals placed on a waiting list. People in the treatment group had been in treatment at least 6 months prior to the second rating (March 20, 2000). The raters (facility dentist and dental hygienist) were not aware of who had participated in each group.
The study was a 2 × 2 repeated measures factorial design with the two groups (treatment, no treatment) both measured over two distinct time periods (March, 20, 1999, March, 20, 2000). Thirty-nine people participated in the treatment group; 40, in the no treatment group.
Each rating was assigned a numerical value, ranging from 1 (excellent) to 5 (very poor). The numerical ratings for both groups were then averaged over the two designated time periods. We analyzed statistical significance using an analysis of variance (ANOVA) and paired t tests. In addition to an average numerical rating, we calculated a statistic termed improvement differential. The improvement differential was obtained by taking the difference between the percentage of participants who received an improved rating from March 1999 to March 2000 versus the percentage of participants who received a poorer rating over the same time span.
Average numerical oral hygiene ratings over the one-year period are compared in Figure 1. Lower numbers indicate better oral hygiene. The results indicate that the groups were not statistically different at baseline rating. People in the treatment group showed statistically significant improvement, t(39) = 3.82, p < .001, as their oral hygiene ratings decreased from an average of 3.42 to an average of 2.97. Oral hygiene ratings for those in the no treatment group did not show a significant decrease; the difference between mean ratings was minimal (3.14 to 3.10). The ANOVA yielded a significant difference between the two groups, F(2, 101) = 5.59, p = .005; those in the treatment group showed greater change in mean oral hygiene ratings than those in the no treatment group.
The examination of the improvement differential indicated that 10 people (25%) in the no treatment group (N = 40) had an improved oral hygiene rating after one year, whereas 8 people (20%) regressed in oral hygiene over that same period, for an improvement differential of 5%. The improvement differential for participants on oral care tolerance plans was 38%, with 18 people (46%) showing improvement and only 3 people (8%) showing regression.
The results indicated that practices can be implemented to improve oral hygiene in individuals with mental retardation living at a state residential facility. Significant improvement was shown over a one-year period when people received individualized plans to improve the quality and consistency of oral care delivery. Minimal improvement was shown during that same time with similarly impaired individuals placed on a waiting list to receive services. Direct care staff working with the individuals on the waiting list received training in general oral care strategies, but this did not appear to have much benefit. It is important to recognize, however, that although direct care staff members were trained on general procedures, we did not examine the degree to which these procedures were implemented. Therefore, the modest results of those individuals not receiving individualized services may be due in part to a lack of implementation. The results of the study may have been more powerful if more standardized criterion for determining oral hygiene ratings were used. However, with agreement among raters being high, it is reasonable to assume that the results were reliable.
Most people with severe and profound mental retardation require assistance with daily oral care. Therefore, it is necessary for direct support staff to ensure that people receive a thorough toothbrushing and other oral care procedures recommended by the dentist. Direct support staff often meet with resistance when trying to provide oral care due to the potential invasiveness of being assisted with such care. The resistance, frequently combined with a rushed schedule and other demands, leads staff to either give up prematurely or ignore oral care altogether. Given the impact that oral hygiene can have on dental and overall health, it is imperative that steps be taken to provide quality and consistent oral care. The results of this initiative demonstrate that a concentrated effort and individualized approach can often result in significant improvements in oral hygiene.
Many clinical questions require further study. As with many treatment plans, initial positive results are often followed by a period of diminished support and maintenance after initial improvement. We plan to continue tracking oral hygiene at this facility to determine whether this improvement is maintained and enhanced. A system-wide policy will likely be needed to ensure that consistent high quality oral care is maintained. Also, investigation of any personal characteristics that facilitate or hinder toleration of oral care, as well as the level of direct care staff compliance with the implementation of treatment recommendations, requires further exploration.
Oral hygiene constitutes a very important part of a person's overall health. Because the purpose of all innovations in the field of mental retardation/developmental disabilities is to help the individuals served to experience a higher quality of life, we need to ensure that these individuals are in good enough health to participate in the increased opportunities available to them. For many people with developmental disabilities, oral hygiene primarily depends upon the delivery of daily oral care by people supporting them. With good effort, instruction, and support, people with poor oral hygiene can show improvement. We believe that the benefits are well worth the investment.
The authors acknowledge the contributions of the Green Valley Developmental Center (GVDC) Dental Department and other members of the Behavioral Medicine Interdisciplinary Workgroup who did not directly participate in the writing of this article but provided valuable input throughout the process. Acknowledgments also go to the University of Kentucky Dental Program for their expert consultation during the initial set-up of our dental desensitization program. Finally, the authors thank Joseph Neumann as well as the members of the GVDC Research and Publication Committee for their thoughtful review and suggestions.
Individualized Oral Care Plans
Development of the oral care plans generally began with an observation by the professional who received the referral. The professional discipline that received the referral varied depending on the nature of the problem (e.g., sensory, oral-motor, behavioral). Oral care was then observed, with the primary caregiver demonstrating typical procedures used with the individual.
Notice was taken of the following: (a) person's diagnosis and medical problems (e.g., reflux, regurgitation/vomiting, dysphagia, history of chronic upper respiratory infection or aspiration pneumonia); (b) chronic dental rating of poor oral hygiene or worse; (c) communication used during the process; (d) environment; (e) infection control measures used; (f) position of the individual during oral care; (g) position of staff while providing oral care; (h) type of tooth brush (e.g., large or small head, hard or soft bristles, 3-sided tooth brush, rechargeable toothbrush, bristle movement, loudness); (i) type and amount of toothpaste; (j) amount of time spent brushing teeth; (k) brushing techniques, such as direction or sequence pattern, angle of brush in relation to teeth/gums, and surfaces covered; (l) special techniques found useful in completing oral care, such as gently stretching out the cheek to allow reaching molars more comfortably; (m) whether teeth are flossed or tongue is brushed; (n) persistent halitosis despite routine oral care; and (o) the person's responses to oral care.
Responses or issues that may have required individualized plans included tearing, coughing, gagging, neck held in extension, bleeding gums, short brushing time by person or staff, aggression, self-injurious behavior (SIB), withdrawal or refusal, signs of pain (e.g., wincing, biting down on the toothbrush).
At this point in plan development, we were able to consult with other professionals, as needed, to provide additional support. Potential supports available included (a) psychology or behavior analysis to evaluate behavioral issues when all other avenues were explored unsuccessfully. (b) a Dental Department referral to rule out dental issues as the cause of pain and for confirmation of brushing techniques or other specialized recommendations; (c) an occupational therapist to assess sensory, swallowing, postural, or independence issues related to maximizing participation and reducing aversive responses (at Greene Valley, a swallowing therapist may be an occupational therapist or a speech–language pathologist); (d) a speech–language pathologist to provide the most effective method of communicating with patients to reduce anxiety and maximize participation, as well as addressing any swallowing issues; (e) a nursing or medical referral to address pain, drug interaction, or side effects of medication; (f) physical therapy to assist with postural control or alternative positioning during oral care; (f) case management to assist with organizing and coordinating an interim review, procurement of special equipment, and patient education as appropriate.
Unit supervisors were asked to assist with coordination and follow-through of dental appointments as well as scheduling daily activities. Direct support staff members were asked to provide day-to-day oral care support either by implementing safe oral care practices or assuring that people brush their own teeth thoroughly. They were also asked to assist with day-to-day education by promoting positive attitudes about oral care and dental appointments.
Components of an Oral Care Plan include name, identification number, home, date of plan, goals, precautions, materials, position of patient, position of staff, procedures, data-gathering forms.
Each plan was reviewed by the person's case manager, conservator, primary care physician, and dentist prior to approval. The Behavioral Management and Human Rights Committees further reviewed plans with more restrictive elements, such as manual restraint related to behavioral resistance. Once a plan was designed, the professional(s) who authored the plan carried it out as written to confirm or modify the plan, as necessary. The author of the plan then trained individual staff members who were responsible for providing oral care with the person. Training ranged from verbal explanation of the plan to verbal explanation plus demonstration by the professional and a competency demonstration by the staff member.
Monitoring of program implementation varied from once a month to quarterly. Monitoring included actual observation of the staff member brushing the person's teeth with immediate feedback given to staff, along with review of the data. Modifications to the programs were made as needed.
General Oral Care Strategies
Before placing the electric toothbrush in the person's mouth, allow him or her to hold the toothbrush and examine it. If an electric toothbrush is used, let the person feel the vibration in his or her hand(s) by turning the handle on. The individual may also need time to get used to the noise it makes.
Once a person is used to the toothbrush, slowly bring the brush to the person's mouth. In general, it is best to move slowly and avoid sudden movements.
Place the head of the toothbrush on gum line at a 45-degree angle and gently brush back and forth. If an electric toothbrush is used, hold the toothbrush steady and let the vibration do the work. You do not need to move the toothbrush back and forth. Hold it at one spot for up to 10 seconds then move it to another spot.
Only a small (pea size or less) amount of toothpaste is needed. The vibrating action of the brush causes the toothpaste to foam, which may lead to gagging if there is too much.
Make sure the person is in a comfortable position during brushing. Most people prefer to sit in a chair with back and arm support. Check the person's dining plan to see whether any special positioning is needed. You should use the same position for oral care that you use for mealtime. Normal positioning for oral care has the person's head at midline with a slight chin tuck.
The person may need touch prompts to open his or her mouth and keep the head in a safe position. Always use a firm touch for individuals who are tactilely defensive (sensitive to touch).
Allow frequent rest breaks while brushing. This gives the person time to breathe, spit, and regain his or her composure. The toothbrush should only be in their mouth for 5 to 10 seconds at a time.
Many people with developmental disabilities are unable to spit. This results in people swallowing toothpaste and all the bacteria and plaque that was just brushed off their teeth. After completion of brushing, either take a damp washcloth and wipe the excess toothpaste from their mouth or dip a toothette (a small stick with a sponge-like head, softer than a toothbrush, that removes food particles) in water or mouthwash and gently stroke it against their teeth. Caution should be used for individuals with nonoral intake. Consult your swallow therapist when working with these individuals.
Authors: Steven Altabet, PhD ( SAltabet@teamsupports.org), Director of Clinical Services, TEAM Evaluation Center, 600 N. Holtzclaw Ave., Suite 100, Chattanooga, TN 37404. Keith Rogers, OTR/L, Occupational Therapist, 9672 W. Dumbarton Pl., Littleton, CO 80127. Elizabeth Imes, MS, CCC-SLP, Certified Speech–Language Pathologist, Physical Nutritional Management Team; Ida Mae Boatman, BA, Graduate Student Assistant, Psychology; and Janice Moncier, Counseling Associate in Psychology, Greene Valley Developmental Center, PO Box 910, Greeneville, TN 37744