By Ellen Moran
People with intellectual disabilities are more likely to have untreated tooth decay, but finding dentists who are willing to provide them with dental care can be difficult. UMass Medical School’s Eunice Kennedy Shriver Center is meeting this challenge through research and training to educate dental professionals and students about making dental visits easier for individuals with intellectual disabilities.
The Shriver Center, part of UMass Medical School’s Commonwealth Medicine division, has received grants for two projects involving oral health. A two-year grant from the National Institutes of Health enabled the Shriver Center, in partnership with Praxis, Inc., an educational technology company, and the Department of Exercise and Health Sciences at UMass Boston, to develop two online courses. A three-year grant from the Centers for Disease Control (CDC) National Center for Birth Defects and Developmental Disability (NCBDDD) financed a project to determine the most effective interventions that may lead to improvements in oral health in individuals with intellectual disabilities.
“It is very difficult for people with intellectual disabilities to find a dentist, particularly once they become too old to continue to see pediatric dentists,” said Richard K. Fleming, PhD, adjunct associate professor in psychiatry at UMass Medical School and associate professor of exercise and health sciences at UMass Boston. Some dentists don’t accept patients with intellectual disabilities because they lack the training to meet the patients’ needs and may not realize that a handful of behavioral supports is all that’s needed to treat the majority of patients.
Patients with intellectual disabilities often have significant anxiety, limited communication skills, and low tolerance for dental procedures. One of the two-hour online courses focuses specifically on treating patients with autism spectrum disorder, who have unique challenges with sensory stimuli in the dental environment, while the other is about treating patients with intellectual disabilities.
“We hope to make it seem more comfortable and manageable for dentists to take more patients with disabilities,” said Helen Hendrickson, MPA, project director for the dentistry online courses. “We think it’s still their duty to make sure people have dental care.”
The online courses will undergo a trial in March with 120 dentists, dental hygienists and dentistry and dental hygiene students taking each course, allowing the research team to evaluate changes in their knowledge, self-efficacy and intention to treat patients with disabilities. They also will provide important feedback before the courses are released publicly. The courses, which are similar to video documentaries, include advice from dental and behavioral experts and interviews with parents, caregivers and even patients with autism and intellectual disabilities. Family members discuss both problems they have encountered with dental visits and welcomed solutions they have experienced when the dental team is prepared, Dr. Fleming said.
For instance, patients with autism might be sensitive to bright light shining in their faces, the suction or vibration of dental tools or the flavor of the dental paste. People with intellectual disabilities may tire more easily and become overwhelmed more quickly than other patients. The recommendations for dental professionals include simple solutions like dimming bright lights, finding professional toothpaste or polish with no taste and giving patients more concise instructions. They might also be a little more involved by showing patients how a procedure will be done in order to reduce their anxiety, learning to recognize signs that a patient cannot tolerate the procedure much longer, and taking breaks or breaking a visit into two to build tolerance, Hendrickson said.
“We inform them, and have patients themselves inform them, about what dental professionals can do to have success,” Fleming said of the training videos.
Fleming and Hendrickson, who wrote the grant that funds the online course project, work closely with other researchers at the Shriver Center who are looking at ways to improve oral health through the CDC project on Oral Health Disparities.
Ways to increase access to oral health and address oral health issues have been developed, but not systematically studied, said Alexandra Bonardi, MHA, OTR/L, clinical assistant professor in UMass Medical School’s Family Medicine and Community Health and former director of the Center for Developmental Disabilities Evaluation and Research at the Shriver Center. She said she hopes the review will encourage people to study whether they’re effective.
Partnering with the American Academy of Developmental Medicine and Dentistry (AADMD), the team reviewed literature describing steps that have been taken to improve oral health. The broad study involved dentists, hygienists, and physicians, who helped with the screening of more than 4,000 articles, and pared them to about 125 articles that are in the final review.
Christine Clifford, MHP, research coordinator for the Oral Health Surveillance/Disparities project, cited four categories of ways to improve the quality of oral health care: prevention strategies, education and behavioral interventions, access, and when and how to use sedation.
Prevention strategies include the use of fluoride varnish, spray or tablets to prevent tooth decay. Desensitization can help lessen fears by using videos to show the individuals the steps involved in a dental visit “to make them feel more comfortable going to the dentist,” Clifford said. Access focuses on the financing and reimbursement for oral health care.
Some dentists are concerned the patients might be disruptive and use sedation. Bonardi said sedation is the first go-to for some dentists who don’t have the training to help make the patient more comfortable. The researchers are looking at why and when sedation, which always carries risks, is used, she said. Ultimately, the project will provide evidence of effective strategies to improve oral health for people with intellectual disabilities and identify areas for further evaluation.
Fleming said he hopes the online courses eventually will be offered as continuing education for practicing professionals and as part of higher education curricula to introduce dentistry students to the disability world.
The ultimate goal held by the National Institute of Dental and Craniofacial Research, the oral health division of NIH, Fleming said, is for the online dental courses “to be developed, tested, used, and five or 10 years down the road, result in far more patients with disabilities being seen and effectively treated.”