Have Healthy Teeth
A Behavioral Intervention to Promote Positive Oral Health in People with Intellectual and/or Developmental Disabilities
Donna B Bainbridge, EdD, PT, AT-Ret, CIFT
Summary: This article describes a University of Montana pilot program designed to improve oral hygiene among adults with intellectual and developmental disabilities. Using adapted toothbrushes, clear instructions, and minimal support from a chosen “buddy,” participants improved brushing habits, reduced plaque and gingivitis, and continued twice-daily brushing after the program ended.
Maintaining good health of the mouth, teeth and gums is important for many reasons. Not only do our teeth help us chew, but they also help us talk and speak clearly. Additionally, taking care of our teeth and gums assist with keeping our teeth for a lifetime.
But new research has also demonstrated the importance of a healthy mouth in reducing the risk of disease. Mouth bacteria can get into the blood and cause it to thicken, predisposing to blood clots that might affect the heart or brain. Healthy gums reduce the risk of cancer and dementia in older adults, and premature births in pregnant women.
Your teeth are the first thing that people see when you smile. So, clean and present unstained teeth with good breath is often the first social interaction that we have with other people.
Poor oral health can be considered a “secondary condition” for people with IDD, a condition that is not part of the original disability but might develop because of the disability. Dental problems are reported in the top ten secondary conditions experienced by those with IDD. Dats from Special Olympics Special Smiles has shown that 46-47% of participants have signs of gingivitis (gum disease), untreated tooth decay (25% US, 37 % global), mouth pain (12% US (15% global) and need an urgent dental referral (9% US, 14% global). While 86% brushed once or more daily, 14% did not brush routinely every day.
The reasons for poor oral hygiene in those with IDD are many, including behavioral problems, mobility and neuromuscular issues like uncontrolled movements or problems with gag and swallow, seizures, gastroesophageal reflux, and visual or hearing impairments. So, brushing teeth twice daily as recommended is a major stressor for the person with IDD and the caregiver in the living environment.
The Rural Institute for Inclusive Communities at the University of Montana developed a pilot program under a CDC grant to address the oral health issues of people with IDD. This program was designed with the input of people with IDD as the designers of the program. The program was developed to address the behavioral aspects of twice daily brushing in a state (Montana) that has limited dental professionals in many counties, few low-income dental clinics in a state where most patients are Medicaid dependent, limited acceptance of Medicaid by many practitioners, and limited practitioner training or experience working with people with IDD.
The participants were adults in supported living environments who were able to independently brush their teeth. Each participant identified a support person (caregiver, family member, friend) who would provide reinforcement throughout the study. The participant-support teams were assigned to one of three groups: double-headed brush, rotary brush, or sonic brush on one side of the mouth while a regular brush was used on the other side as a control. To rule out any impact of handedness, side of brush use was randomly assigned. Teams were taught correct use of the
brushes with modifications as needed and given laminated cards to mount by their mirrors to show which side to use each brush. Each participant was given a tube of toothpaste and instructed to brush 30 seconds in each quadrant of the mouth on both sides of the teeth. The support person provided ONE daily prompt plus bi-weekly verbal reinforcement. Each team decided on the type of support (e.g, phone call or message, direct message, note). The type of support given, and the time involved were noted on a log by the support person.
A dentist examined each participant to outline basis dental status. Each participant was assessed by a dental hygienist with the Simplified Oral Hygiene Index for Debris and Calculus, the Lobene Stain Index, and the Gingivitis Index prior to full teeth cleaning, then reassessed at start of study (one week after cleaning), and at the conclusion of the study (6 weeks). The Gingivitis Index was also performed after weeks 1 and 3.
Results demonstrated significant positive changes on all screening tools from beginning to end of the study (reduced plaque, gingivitis, and debris). Although the participant numbers did not permit us to assess the effect of brush type, all novel brushes seemed more effective at reducing gingivitis and plaque. Participants preferred mechanical brushes as well.
Participants reported that they liked having a ‘buddy’ to remind them to brush. They stated that they felt better and liked having clean teeth. They also stated that they were more ready to smile and talk, as they had clean teeth with no food in them.
Support people spent an average of 36 minutes weekly providing support. Although participants were initially neutral about reinforcement, they were positive by the end of the study.
A post-intervention call 6 months after the program indicated that the majority of the participants were still brushing twice daily.
This program suggests that with clear instructions and minimal support, adults with IDD can improve and maintain good oral hygiene. Many public health and home settings could utilize these methods to support ongoing positive behavior change with minimal effort and reduce the need for more expensive and extensive oral care. Other home-based programs have shown easy acceptance by staff and caregivers, so these programs offer a low-cost minimally invasive way to encourage good oral hygiene.
Recognition of the University of Montana Rural Institute, Montana Disability and Health Program for the CDC grant that provided funding for this program.
About the Author
Donna B. Bainbridge, EdD, PT, AT-Ret, CIFT, is a physical therapist, educator, and faculty affiliate at the University of Montana whose work focuses on fitness, wellness, aging, and fall prevention for people with intellectual and developmental disabilities. She previously served as Special Olympics Global Clinical Advisor for Fitness, helping develop and expand FUNfitness screenings worldwide. Her current research interests include wellness and fall-prevention programming for adults with IDD.