Learning Disability Dental Blog

Advice from a dentist for adults with Learning Disabilities and their carers.

Please note: Dental care must be tailored to the individual by attending for a dental visit.

Dental disease

The two main diseases (things that can go wrong with the mouth), are tooth decay (holes in the teeth) and gum disease (sore, bleeding gums).

Plaque (the creamy, sticky deposit you can see on your teeth), is full of bacteria. To see it properly you need to lift your lips away so we can see your gums.

Plaque and gum disease

Bacteria in the oral cavity attach to the tooth to form a sticky, colourless “plaque” biofilm on teeth. The plaque that is not removed by brushing and flossing harden and form “calculus”. Calculus is difficult to remove by simple brushing and requires professional cleaning by a dentist.

When plaque stays around our teeth and gums it makes the gums red and sore and puffy. The more plaque there is and the longer it is left there the more red and sore they will become. They may bleed when the teeth are brushed. If you brush the plaque away the gums will become healthier. Healthy gums look pink, firm and do not bleed. If the gums bleed, continue brushing there because you will be getting rid of the plaque that is causing it. A dentist or hygienist may recommend brushing in-between the teeth. They may show you special brushes which go between the teeth.

Tooth decay

If you eat foods and drink drinks with certain sugars, often through the day (and night!), it is more likely that you will get holes in your teeth (decay). These holes can cause pain and can mean having a filling or tooth removed. Some sugars are ‘hidden’, so it is important to look at food labels.

The dental clinic and treatment

New environments can be intimidating for us all and it is very important that the patient gets used to a dental clinic and the team. It may require extra time, storyboards and visits to build trust. Once trust is built, regular dental visits are very important as we get older and personal circumstances change.

If someone with a learning disability is not able to receive any necessary dental treatment with local anaesthetic (numbing) it may be that ‘conscious sedation’ or ‘general anaesthetic’ is suitable. The decision is usually based upon individual needs, the type of dental treatment required, and any relevant medical details.

When visiting the dentist, everyone should feel able to make their own decisions where possible. To help in decision-making, communication tools or bringing someone close to the patient, to the dental appointments can be useful.

The main options if you have a Learning Disability can include:

- General dental practice (GDP) 

  • This depends on medical conditions and/or ability to have local anaesthetic (numbing) for dental treatment. 
  • The GDP should have a plan in place if you are unable to receive dental treatment in this setting. This may include a referral pathway to secondary care; Community Dental service (CDS) or Hospital Dental service (HDS), depending on individual dental needs.

- Community Dental Service and Hospital Dental Service

  • You usually need a referral from a GDP, carer, family member or even sometimes your General Medical Practitioner. CDSs can sometimes provide sedation services and HDSs may offer either sedation or general anaesthesia if required.

- Domiciliary Dental Care (dental care at home)

  • If you cannot attend a dental clinic. There usually should be a referral from your doctor or GDP to the CDS or HDS and each department will have specific criteria for patients to receive this care.

On the NHS choices website, you will be able to search for dental services in your area.

Dental information provided to patients

All information provided about the dental treatment should be at a suitable level for understanding. You could ask the dentist if they have any ‘easy-read’ information about different treatments. MENCAP charity produce story books about visiting the dentist.

Tooth brushing

Tooth brushing may be better at certain times of the day to build it into daily routine. If totally independent brushing does not get rid of all the plaque from all the tooth surfaces, its best to have assistance at the level which is appropriate to the individual. This could mean; supervised brushing, ‘hand-on-hand’ or may mean providing all of the tooth brushing.

Toothbrush

There are many varieties of toothbrushes nowadays.

Manual or electric toothbrush choice will be based on the patient’s ability to remove plaque. It is important to choose a small headed, medium soft toothbrush. If brushing is particularly difficult, sometimes the dentist will recommend a brush called the ‘collis-curve’. They can allow the brushing of more than one surface of tooth and gum at once. These can be sourced online.

If a small, narrower handle is difficult to hold, a ‘regular toothbrush’ handle can be adapted, for example with a foam ball. Ask the dentist about specific handle adaptations if this is the case.

Whichever toothbrush you use, it should be replaced as soon as the head looks frayed or splayed.

Toothpaste

Toothpaste on a dry toothbrush means less mess and toothpaste fluoride will not be diluted when compared with a wet brush. Some people like a minty taste that is most frequently in toothpastes. For those who do not like the taste, flavourless toothpastes exist and some can be sourced online, e.g. ‘oranurse’. You will need to check with the dentist whether this is the right toothpaste to use as sometimes we recommend higher levels of fluoride in the toothpaste due to presence or risk of dental disease.

It is important not to rinse any spare toothpaste away after brushing. You need to speak with the dentist if the person you are assisting has any swallowing difficulties.

Anything other than natural teeth

If the individual wears false teeth, they require a different method to keeping them clean. Storage of dentures when they are not worn is also very important. Ask the dentist how to care for the specific denture type.

Dental check-ups

After seeing the dentist, patients should be recommended the frequency of dental reviews. This is specific to each patient based on the amount of oral disease and risk factors.

It is important to see the dentist regularly because they should check not just the teeth and gums but other areas of the mouth such as the tongue, palate and inside the cheeks. 

Cancer Research UK informs us that smoking and alcohol are linked with this disease so it is important that everyone avoids these habits and seeks ‘stop-smoking’ advice. Your dentist or doctor can point you in the direction of these services if required.

Sources of information

NHS Choices ‘Find dentists services’ https://www.nhs.uk/service-search/Dentists/LocationSearch/3

BSDH Integrated care pathway for patients with learning disabilities, 2012 http://www.wales.nhs.uk/documents/BSDH_Clinical_Guidelines_PwaLD_2012.pdf

Mencap Accessible information Standard, 2007 https://www.mencap.org.uk/advice-and-support/health/accessible-information-standard  

NICE Dental visit recalls, 2004 https://www.nice.org.uk/guidance/cg19/resources/dental-checks-intervals-between-oral-health-reviews-pdf-975274023877

Department of Health/Public Health England; ‘Delivering better oral health: an evidence-based toolkit for prevention.’ 2017 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/605266/Delivering_better_oral_health.pdf

Cancer Research UK, Oral Cancer risk factors, 2017 http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/oral-cancer/risk-factors

Dr Brooke Zaidman BDS, MFDS, MSc student in Special Care Dentistry at King's College London Dental Institute.