Introduction

The changing demographics of our population, along with advances in medical and social systems, have resulted in a number of people with special needs who need oral health services rising dramatically (U.S. Department of Health and Human Services, 2000; United States General Accounting Office, 2000; Glassman & Miller, 2006; Glassman & Subar, 2009; IOM and NRC, 2011). In this context, people with special needs refers to those individuals who have barriers to achieving good oral health primarily because of a disability or medical condition. This includes people who are elderly, people who have disabilities, and those who may also have complex medical, physical, and psychological problems.

People with special needs have more dental disease, more missing teeth, and more difficulty obtaining dental care than other segments of the population (Oral Health America, May 2000; Waldman, Perlman, & Swerdloff, 2000; Waldman, Rader, & Perlman, 2009). It is harder for people with special needs to find sources of dental care, and once a source of care is located, it can be more difficult to render dental treatment. Deciding on adequate treatment may require balancing complex medical and social factors and may sometimes require the use of sedative medications or even hospital treatment under general anesthesia. Many people with special needs are dependent on others to locate and arrange for dental treatment. Some caregivers are not themselves aware of the consequences of untreated dental disease and may not be aware of or use procedures known to prevent dental diseases. These factors can result in pain, suffering, and social stigma in these populations beyond that found in other segments of our society (Horwitz, 2000; Schriver, 2001).

It is clear that it is far better to prevent dental disease in people with special needs rather than attempt to treat disease that has already developed, as it is in all populations. However, the difficulty providing treatment for people with special needs makes this focus on prevention even more imperative in this population.

Even with a focus on prevention, there are challenges with establishing effective preventive practices in people with special needs. As indicated previously, many people in these groups are dependent on caregivers to perform preventive practices. Additional challenges may come from the presence of xerostomia, which is a side effect of many psychotropic and other medications used by people in this group. Some people and their caregivers may not understand how to prevent dental disease. Some people have physical problems that make it difficult for them to perform preventive procedures. Some people are resistant to performing these procedures. All these obstacles present challenges to maintaining dental health not experienced by most individuals in our society.

Overcoming Obstacles to Oral Health

Many people have developed techniques and programs to prevent dental disease in people with special needs (Glassman et al., 1994; Miller et al., 1998; CDC, 2001). The training package Overcoming Obstacles to Oral Health: A Training Program for Caregivers of People with Disabilities and Frail Elders is currently in its 5th edition (Glassman et al., 2011). It is designed for caregivers of people with disabilities and is organized to address four primary barriers:

• Information obstacles: Does the individual or their caregivers understand what needs to be done?
• Physical obstacles: Can the individual or their caregivers physically perform needed procedures?
• Behavioral obstacles: Is the individual resistant to performing or having someone else perform preventive procedures?
• Organizational obstacles: Is there a system in the home, community, or facility where the individual resides that can support and help them and their caregivers overcome the other three obstacles?

These materials are available in a package with a CD and DVD which include workbooks and administrators and trainer’s manuals, training videos, Powerpoint presentations, pre- and posttests, and other resources. There is an emphasis on developing an individual oral health plan for each individual.

Overcoming Information Obstacles

Given the fact that people with special needs can be dependent upon a caregiver to carry out preventive practices, it is critical that the caregiver as well as the individual understand the causes of dental diseases and techniques for prevention. It is unlikely that a caregiver will do more for the individual they are caring for than they will do for themselves. Therefore, caregivers must understand the importance and benefits of oral preventive practices as well as the techniques to accomplish them. It is important to start with an assessment of the knowledge and skills of the caregiver and the individual. When making such an assessment, it is important to consider the setting and strategies for assessing their level of knowledge and conveying new information. Issues such as socioeconomic status, race, ethnicity, age, gender, native language, cultural beliefs, how the individual best receives health information, and the best setting for delivering information are important to understand and incorporate in any group or individual oral health literacy assessment or improvement efforts (IOM and NRC, 2011). In many circumstances, providing the traditional short lesson on “oral hygiene” or even a longer “anticipatory guidance” session delivered at the end of a dental appointment in a dental office may not have any impact on the subsequent behavior of the individual or their caregivers (Glassman & Miller, 2006; American Academy of Pediatric Dentistry, 2008; American Academy of Pediatric Dentistry, 2009). For some individuals, effective health promotion messages may best be delivered in a community setting, such as the individual’s residence, a school, a work program, or a location where they receive other social or general health services. It is critical that oral health professionals who work in dental offices and clinics recognize the limitations of delivering oral health messages in the dental office setting and the value of partnering with community-based resources.

Effective preventive information can be delivered in a “pyramid” training program where the dental professional trains a home health nurse or a residential facility manager or someone else who can then be responsible for training others in the techniques learned. Such a training program can greatly magnify the effectiveness of the dental professional. The Overcoming Obstacles training materials are designed to be used in this “pyramid” training approach.

When discussing “daily mouth care,” the term preferred by the author, it is important to use simple language, referring to pictures and simple diagrams whenever possible, delivering small amounts of information at any one time, testing understanding, repeating information and adding new information at subsequent sessions, and creating an environment where individuals or caregivers feel comfortable asking questions. It is also important to tailor messages to the values and desires of the person you are talking to. For example, motivational interviewing is a technique for understanding the beliefs and values of the individual and customizing oral health strategies to help the individual achieve their own goals. This method has been shown to result in greater improvement in oral health than traditional health education (Weinstein, Harrison, & Benton, 2006).

It is also critical to understand that no matter how well delivered the message, it may not translate into behavior change (Freeman & Ismail, 2009; Satur et al., 2010). A 2000 report by the Institute of Medicine on social and behavioral research stated that “To prevent disease, we increasingly ask people to do things that they have not done previously, to stop doing things they have been doing for years, and to do more of some things and less of other things. Although there certainly are examples of successful programs to change behavior, it is clear that behavior change is a difficult and complex challenge. It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change” (IOM, 2000). In fact, in a study published in 2006, Glassman and Miller demonstrated that caregiver knowledge about preventive procedures was improved after training, but this was only translated into behavior change with incorporation of new techniques into daily routines after a dental assistant observed the prevention session in the residential environment and provided hands-on, real-time coaching (Glassman & Miller, 2006).

Other information needs include assessing the individuals risk for future dental disease using a method such as the Caries Management by Risk Assessment (CAMBRA) model (Young, Featherstone, & Roth, 2007) and the need for medical management (Glassman & Miller, 2003; Glassman et al., 2003).

Overcoming Physical Obstacles

Another barrier to prevention of dental disease is physical barriers. Some people understand what needs to be done, but lack the musculature, dexterity, or coordination to do it. For many people, the physical barrier is simply the inability to grasp a toothbrush or to manipulate dental floss. There are numerous adaptations and aids that can help overcome these physical barriers. Figure 22.1 shows toothbrushes that have been adapted with a larger handle using a tennis ball or bicycle handle grip. Figure 22.2 shows someone with limited dexterity using a large foam ball as a means of picking up a toothbrush. Similar adaptation can be made for floss holders. These adapted instruments can be much easier to grip than conventional implements.