Trauma is common in severe learning disability, severe epilepsy and in abused and vulnerable individuals (Figs 4.1, 4.2). Learning disabilities, cognitive impairment, delirium (common among the acutely ill/frail elderly), and dementia (occurring in as many as 50% of institutionalised elderly) represent serious barriers to trauma and pain assessment. Management of trauma in these special needs groups should involve a coordinated team approach, where carers, and other health care professionals, such as general medical practitioners, may be able to assist in ensuring the correct diagnosis is made and appropriate treatment is offered.
Attrition (Fig. 4.3) is common (especially in males), where the diet is very coarse, where there is bruxism, or where the teeth are defective, as in dentinogenesis imperfecta or Ehlers–Danlos syndrome. Furthermore, tooth wear may be more common in individuals with intellectual disabilities. Restorative procedures may be needed, including composites and advanced restorative techniques.
Bernhardt, O, Gesch, D, Splieth, C, et al. Risk factors for high occlusal wear scores in a population-based sample: results of the Study of Health in Pomerania (SHIP). Int J Prosthodont. 2004; 17:333–339.
Rees, JS, Jara, L, Ondarza, A, Mistry, P, Laing, E, Odell, O. A comparison of tooth wear in children with Down syndrome, children with other intellectual disability and children without disability. J Dent Oral Health. 2004; 5:3–12.
Higher levels of dental caries may be present in some individuals with special needs (Fig. 4.4), with the level of risk dependent on a complex interrelationship between socioeconomic factors and access to oral health care, concurrent illness and its treatment. Examples of factors which may increase caries risk include: xerostomia due to Sjögren’s syndrome, radiotherapy, or secondary to the use of tranquilisers or other psychoactive anticholinergic drugs medications containing sugar special diets, including those that require frequent snacking poor motor control of the cheeks, lips and tongue dysfunction in the arms and hands general debilitation/poor motivation due to concurrent illness or chronic depression.
Frequent exposure to acidic substances may result in the loss of enamel from the tooth surface by chemical erosion (Fig. 4.5). Erosion may be the result of intrinsic or extrinsic sources of acid.
The intrinsic sources include: gastro-oesophageal reflux, which may be due to sphincter incompetence, increased gastric pressure (due to obesity) and increased gastric volume vomiting (due to pregnancy, eating disorders) rumination.
The extrinsic sources include: dietary acids, such as carbonated beverages, alcoholic drinks and citrus foods medication such as vitamin C and iron preparations, ecstasy, anti-asthmatic medication and excessive aspirin some mouthwashes and saliva substitutes that are also acidic environmental contact with acids as part of work or leisure activities.
Immediate management includes desensitisation through the use of fluoride toothpaste and mouthwashes, and implementation of appropriate preventive strategies aimed at reducing the acid exposure. Interim and long-term treatment includes the provision of temporary diagnostic restorations, ongoing monitoring of disease, definitive restorative work where appropriate, and modification and reinforcement of preventive advice.
People who have impaired manual dexterity can find it difficult to achieve good levels of oral hygiene, and thus gingivitis and periodontitis can ensue. Furthermore, early, severe periodontal disease can occur in children with impaired immune system or connective tissue disorders, with periodontitis often particularly aggressive in some genetic syndromes (e.g. Down syndrome). Regular professional cleaning by an oral health care provider, local or systemic antibiotics, and modified instructions on home care may be required to control existing periodontal disease. The patient may also need to help with daily toothbrushing, and cleaning aids may need to be adapted. For those patients at increased risk of periodontal disease, frequent appointments with an oral health care provider may be necessary.
Gingival overgrowth is not uncommon in patients receiving immunosuppressant medication (e.g. ciclosporin), antihypertensive calcium-channel blocking drugs (e.g. nifedipine) or anticonvulsants (e.g. phenytoin), and may further compromise periodontal health (Fig. 4.6).
Drooling is usually caused by true excess salivation, but may result from the inability to retain saliva within the mouth, or problems with swallowing. The social implications of drooling include embarrassment, social isolation and alienation for both the individuals and their families. The constant exposure of skin to saliva can cause a rash around the mouth, chin or lips, chapping of lips and infections around the mouth. Not only does it cause discomfort or even pain, but the sores may be considered unsightly. Clothing may need changing several times each day, which can become very laborious for the family or carers. They may opt for the patient to wear a bib, which results in further stigmatisation.
Furthermore, people who drool are at increased risk of inhaling saliva, food, or fluids into the lungs. This may lead to respiratory infection if reflex mechanisms (such as gagging and coughing) are also impaired.
True salivary hypersecretion is usually caused by: food local factors such as teething or oral inflammatory lesions physiological factors such as menstruation or early pregnancy digestive origin, both functional (motility disorders and oesophageal spasm) and organic pathology (ulcers, hiatus hernia) medications (those with cholinergic activity such as pilocarpine, tetrabenazine, clozapine or bethanecol) nasogastric intubation.
False sialorrhoea, or apparent hypersalivation, is caused not by excess saliva production but by an inability to swallow a normal amount of saliva caused by: neuromuscular dysfunction: as a result of muscular incoordination or neurological disorders seen in Parkinson’s disease, amyotrophic lateral sclerosis, bulbar palsy, cerebral palsy, learning disability, epilepsy, autonomic neuropathy, Riley–Day syndrome, some psychoses and tumours – especially those near the IVth ventricle poor lip seal and malocclusion, usually linked to learning disability abnormal head position as seen in progressive bulbar palsy pharyngeal or oesophageal obstruction, such as by a neoplasm.
Treatment of drooling involves the management of the underlying cause if possible, and treatment of any concurrent oral disease. Maintaining the patient’s head in an upright position may help to minimise symptoms. Additional strategies include:
Physiotherapy approaches, such as a modified Andreasen monobloc appliance, Innsbruck Sensory Motor Activators and Regulators (ISMARs) or the Castillo–Morales technique where a palatal appliance encourages lip and tongue control.
• Atropinics such as benztropine or benzhexol which are theoretically useful to control sialorrhoea, although many, such as scopolamine (hyoscine) or ipatropium bromide, are of little practical value because of adverse effects. However, transdermal scopolamine using dermal patches has been shown to be effective within 15 minutes, and lasts up to 72 hours. Itching under the patch and flushing appear to be the main adverse effects.
• Glycopyrrolate, a quaternary ammonium compound with anticholinergic effects, has minimal side effects to the central nervous system because it penetrates the blood–brain barrier poorly yet has a long-lasting antisialogogue effect. Oral glycopyrrolate 0.4 mg 3× daily is effective in many adults with sialorrhoea though it may cause some flushing and urinary retention.
• Antihistamines are sometimes used. Propantheline bromide 15-30 mg may be effective but is contraindicated in glaucoma, myasthenia gravis and bowel or bladder obstruction. Methantheline is an alternative.