Bringing Oral Care to Children with Special Needs in Israel
Images Courtesy of Dr. Joseph Shapira.
By Prof. Joseph Shapira, DMD
Article author Prof. Joseph Shapira, DMD
Individuals with disabilities make up about 20% of Israeli society, over 1.5 million people (1). The prevalence of disability in the population is similar to other countries, with the CDC in the United States reporting 26% prevalence of disabilities in the 2022 population, up 19% from 2000.
In Israel, this significant sector of people with disabilities spans across all ethnicities, religions, and socio-economic segments.
“Globally, steps have been taken to support this segment of the population, with legal mandates which empower individuals with disabilities, and with the development of educational and therapeutic programs for those with disabilities.”
Shalva, The Israel Association for the Care and Inclusion of Disabilities, was established in 1990 to address the full spectrum of needs of an individual with disabilities and their family. Shalva provides a therapeutic framework for each stage of life and has programming to address the challenges that individuals and their family face throughout the lifecycle.
Shalva was established by Kalman and Malki Samuels, parents of a child with disabilities, and they’re tuned into the specific challenges that families face in taking care of their child with disabilities. One such challenge is the difficulty in maintaining oral hygiene.
A 2020 survey of 300 parents of children with Down syndrome in the US showed that 50% of children’s teeth weren’t brushed every day (2). Parents cite a tremendous challenge in gaining their child’s cooperation in toothbrushing — a challenge faced by many parents but made all the more challenging with a child with disabilities. As these parents face numerous daily responsibilities and challenges in raising their child with disabilities, it’s understandable that their oral hygiene doesn’t get prioritized.
“Research has shown a real need for enhanced oral health, specifically for children with disabilities, who are among the underserved in our society" (3). According to a 2009 study in the United States, 81% of children with special health care needs require enhanced preventive dental care. In addition, dental care remains the most frequently cited unmet health need for children with special health care needs (4).”
There is a higher prevalence of oral disease, dental caries, and missing teeth in individuals with disabilities who face greater difficulty getting dental care than the general population (5). Tooth decay is a top chronic infectious disease among children, more common than asthma and childhood obesity, affecting about half of the children in the US by age 6. (6)
The trend of poor oral health in the disability community explains increased periodontal disease among individuals with disabilities. Recent research shows that oral disease is linked to general diseases like diabetes and heat disease. And that excess oral bacteria place the predisposed fragile health of individuals with disabilities at an increased risk of infection. (7,8).
The availability of various social service opportunities within normative communities has resulted in a positive shift in preference among families to raise children with disabilities at home rather than in institutions (9). However, once residing in the family home, individuals with disabilities and their families find the specialized care infrastructure to be inaccessible and unaffordable.
As such, research studies in Israel and around the world reveal an ironic dichotomy—individuals with disabilities being raised in their homes suffer greater oral health risks than their institutionalized counterparts, as they’re less likely to receive specialized oral hygiene guidance in the less supervised home environment. And that puts them t a higher risk of developing dental caries (6).
The Shalva Oral Hygiene Training Clinic (OHTC) of the Oral Health for Everyone (OHEV) initiative fills this critical void. OHEV, the Hebrew word for Love, was established within Shalva to respond to the most current oral hygiene needs of Israel’s disability community. Through education, specialized dental care, and individualized oral hygiene training, the OHEV program empowers children with disabilities and their families to improve their health and potential for social inclusion.
“The OHEV program is a unique asset of the Shalva National Center and the first dental clinic of its kind for the disability community in Israel, focusing on proper oral hygiene practices to prevent the need for invasive dental treatments.”
The clinic uses preventative medicine to encourage the life-long oral health of individuals with disabilities and to improve their quality of life. Through the program, Shalva offers dynamic educational seminars for children with disabilities and their caregivers, as well as specialized dental hygiene care and individualized oral hygiene training according to the needs of each participant, all at no cost to the child or their families.
OHEV’s dentist and dental hygienists work with Shalva’s special educators, therapists and parents to develop individualized innovative mechanisms, like specially constructed toothbrushes and developed toothpastes to enable each participant to successfully adopt an oral hygiene routine best suited to their individualized needs. The outcomes of such interventions include an established oral hygiene routine that’s realistic for families to incorporate into their child’s routine, and the prevention of painful high-risk dental treatments and related expenses.
The clinic’s facility is completely disability accessible and includes dental chairs and sinks designed at different heights to accommodate all ages and abilities.
The OHEV initiative at Shalva is integrated into Shalva’s 3 bands of age-based programming for Shalva’s participants from birth to age 21.
Early Intervention Oral Health
Shalva's Me and My Mommy program provides a unique framework for infants with disabilities to receive comprehensive weekly rehabilitation therapy and for mothers to find support and practical tools to gain confidence in raising their child with disabilities. In the context of this program, the OHEV program’s dental team gives a monthly seminar to 25–30 mothers with their babies focusing on the following dental developmental milestones:
The development of teeth and the process of teething (drooling, sore gums, fever, etc)
Guidelines for healthy feeding habits (no sugars before bedtime)
Guidelines for healthy nutrition (less sugars)
Oral hygiene home care for babies (soft bristled toothbrush, a wet washcloth, gauze, etc)
Nursery and Preschool (ages 1–6)
The core program model of the OHEV program focuses on about 130 children who are part of our daycare, nursery and preschool programs. This program has 5 components:
1. Educational Guidance:
Dental Hygienists lead age-appropriate sessions for our classrooms of toddlers and young children. Through group games, modeling and activities, children are taught proper teeth brushing and oral hygiene practices. (Figs 2 & 3)
Figure 1
Figure 2
Fig 1 - 2: Through seminars, group games, and modeling,
children are taught proper teeth brushing
2. Hands-On Skill Development:
During a series of one-on-one sessions, our dental hygienists work with the children and staff to map out each child’s dental needs and challenges. Then they develop individualized solutions, including creating assistive tools for prolonged mouth opening, providing various toothpaste flavors, and constructing toothbrushes at atypical widths and lengths to accommodate the dexterity and mobility limitations of each child. (Figs 3–6)
Figure 3
Figure 4
Figure 5
Figs 3–5: Dental Hygienist works personally with the children and staff to map out each child’s dental needs and challenges
Figure 6
Fig 6: Creating “Homemade” assistive tools for prolonged mouth opening — A sterilized rubber doorstop
3. Therapists' education:
Teaching therapists and special educators (e.g. kindergarten teachers, communications clinician, speech therapists, special educators) how to implement oral health practice routines in the classroom and within the daily schedule of Shalva programs (e.g.: routine toothbrushing after breakfast). (Figs 7–9)
Figure 7
Figure 8
Figure 9
Fig 7 - 9: Implementation of oral health practice routines in the classroom and within the daily schedule by special educators and therapists
4. Quarterly Clinic Visits:
The children receive quarterly applications of fluoride varnish by a Specialized Pediatric Dentist (Fig 10). This slow releasing fluoride paste has been proven to reduce morbidity of dental caries by up to 98% (10).
Figure 10
Fig 10: Quarterly application of fluoride varnish
5. Parents Forum:
The OHEV program dental staff host an annual event for parents of Shalva program participants and their children with disabilities to learn and discuss the importance of developing a healthy oral hygiene routine. Parents and children receive information and practical guidance regarding enforcing daily oral hygiene as part of the daily routine at home.
Parents are guided in how to tackle challenges of toothbrushing at home, for example, prioritizing toothbrushing before bed.
6. School Age program (ages 7–21)
The After School Activity program brings over 250 children and young adults to Shalva each afternoon to participate in a range of recreational, therapeutic activities at our campus. In the context of this program, participants receive refreshed oral hygiene routine instruction in addition to oral examinations and Fluoride varnish application.
OHEV’s preventative oral health initiatives have been highly successful since the establishment of our clinic seven years ago. The results show the awareness and involvement of more and more parents in establishing positive oral hygiene habits, helping their children with disabilities avoid more invasive dental treatments down the line.
The entire staff of the educators and therapists have been educated on the importance of maintaining the health of the children's teeth and are partners with parents in making sure that healthy habits are a mainstay in the children's daily life.
The OHEV Program at Shalva is an important initiative which complements Shalva’s range of lifecycle programming and sets a solid foundation for oral hygiene routines in infancy, childhood, and towards adulthood.
In today’s aesthetic driven society, Shalva’s Oral Health initiative enhances the health and appearance of our program participants and positively encourages their successful social inclusion.
Through the Shalva Institute, the organization’s educational branch, Shalva shares our research and learned knowledge, presenting Shalva’s unique therapy and inclusion programming, including OHEV, as replicable models. By highlighting the need for increased access to oral health services for individuals with disabilities, and by presenting our educational models and programmatic interventions, Shalva promotes inclusion as it relates to oral health and beyond, reaching individuals, communities and organizations far beyond our center’s walls.
Barlev L, Keren-Abraham Y, Haber Y and Admon-Rick G, Editors: “People with Disabilities in Israel 2017”. Myers-JDC-Brookdale institute for Research on Disabilities and ministry of Justice Commission for Equal Rights of People with Disabilities.
Stein-Duker LI, Richter M, Lane CJ et al. “Oral Health Experiences and Challenges for Children with Down Syndrome: Reports from Caregivers”. Pediatric Dentistry 2020; 42: 430-5.
Shapira J, Efrat J, Berkey D, Mann J. “Dental health profile of a population of mental retardation in Israel.” Journal of Special Care in Dentistry: 1998; 18:4, 149-155.
Lewis CW. “Dental care and children with special health care needs: A population-based perspective”. Acad Pediatr 2009; 9:420-6.
Glassman P, Miller C. “Dental disease prevention and people with special needs.” Journal of the California Dental Association, 2003.
Donly K. “A national children's dental health month, letter from AAPD president”, 2023
Tiller S, Wilson KI, Gallagher JE. “Oral health status and dental service use of adults with learning disabilities living in residential institutions and in the community.” Community Dent Health: 2001; 18:167-71.
Preshow, PM. “Periodontal disease and diabetes.” J Dent: 2009; 37(8): 575-7.
Sigal Alison “Time to Improve Access to Oral Health Care for Persons with Special Needs.” J Can Dent Assoc 2009; 75(7):517-9.
Weintraub JA, Ramos-Gomez F, Jue B et al. “Fluoride varnish efficiency to prevent early childhood caries”. J Dent Res 2006; 85:172-6
About the author - Prof. Joseph Shapira
Dr. Joseph Shapira is a Professor Emeritus in Pediatric Dentistry and was the Chair of the Depart. of Pediatr. Dentistry, at the Hebrew University-Hadassah Faculty of Dental Medicine, Jerusalem, Israel.
He also serves as the Director of the Prevention Program for Oral Health at SHALVA.
Prof. Shapira has dedicated his professional life to the education, treatment, and research for children with special needs and high-risk medically compromised children, including the use of sedative agents to manage anxiety and behavior control.
Prof. Shapira has published more than 110 articles in refereed International Journals and lectures on these subjects around the world.