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Preventing oral health problems
INTRODUCTION
In most respects preventing oral diseases among people with disabilities involves using the same strategies that are employed with other segments of the population. However, there are a number of unique factors that make preventing oral diseases among people with disabilities more complex than with other segments of the population and require additional strategies to be successful. These include the following:
- People with cognitive impairments may not understand the importance of having a healthy mouth or what needs to be done to have a healthy mouth.
- People with physical limitations may not be able to perform needed procedures.
- Some people may be resistive to performing mouth care procedures or to having someone else help them or perform these procedures for them.
- Some people with disabilities have primary or associated medical problems that increase their risk for having poor oral health. Among other things, they may take one or more of the more than 400 medications that cause xerostomia (Oral Biotech 2011; Turner & Ship 2007).
- Many people with disabilities are dependent on others for activities of daily living, including mouth care activities. Some caregivers have limited understanding about the causes of oral diseases or methods to care for their own mouth, let alone the mouth of the person they are caring for. Even when caregivers value prevention and know how to perform preventive procedures, it is more complex for oral health professionals to help prevent oral diseases when there is a third party involved.
In addition to the challenges faced by people with disabilities or their caregivers with understanding and performing preventive procedures, many people with disabilities have more dental disease and more difficulty obtaining dental care than other segments of the population (U.S. Department of Health and Human Services 2000; Oral Health America 2000; Haavio 1995; Feldman et al. 1997; Waldman et al. 2000; United States General Accounting Office 2000; Glassman & Miller 2003; Cohen et al. 2011).
OVERCOMING OBSTACLES TO ORAL HEALTH
The authors have developed a set of training and organizational materials over the past several decades to address the challenges in improving and maintaining oral health for people with special needs. The materials, called Overcoming Obstacles to Oral Health, are currently in their 5th edition (Glassman et al. 2011). The materials address obstacles to oral health in four areas. These four areas should be the focus of any program to maintain oral health for people with disabilities. They are:
- Overcoming information obstacles—does the individual or his or her caregivers understand what needs to be done?
- Overcoming physical obstacles—can the individual or his or her caregivers physically perform needed procedures?
- Overcoming behavioral obstacles—is the individual resistant to performing or having someone else perform preventive procedures?
- Overcoming organizational obstacles—is there a system in the home, community, or facility where the individual resides that can support and help his or her caregivers and the individual overcome the other three obstacles?
OVERCOMING INFORMATION OBSTACLES
The first area to assess when working with an individual or caregiver is the person’s level of understanding about the value of good oral health, the causes and consequences of poor oral health, and the procedures to perform to maintain good oral health. When making such an assessment, it is important to consider the setting and strategies for assessing the level of knowledge and conveying new information. Issues such as socio-economic 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 (Institute of Medicine 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 his or her caregivers (American Academy of Pediatric Dentistry 2009; Glassman & Miller 2006). 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 the person receives 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. A separate chapter in this book describes the importance and use of community-based systems of care.
Whatever the circumstances where oral health messages are delivered, it is important to do so using 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.15 Even more significant than delivering messages in the optimum time and place and using the message delivery strategies described above is the ability to tailor the message to the beliefs and values of the person being addressed. 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 his or her own goals. This method has been shown to result in greater improvement in oral health than traditional health education (Weinstein et al. 2006).
In addition to understanding the best strategies for delivering oral health information, it is also important to understand that providing information, even when it results in knowledge increase, does not necessarily lead to behavior change (Freeman & Ismail 2009; Satur et al. 2010). In fact, 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” (Institute of Medicine 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).
The next consideration in overcoming information obstacles is deciding what information to provide. The authors recommend starting with the benefits of performing oral health preventive procedures. Particularly when working with caregivers it is critical that they understand why improving the oral health of the person they are supporting is beneficial to the caregivers themselves. Benefits for caregivers can include reduced mouth odors, making it more pleasant to be with the person; reduced acting-out behaviors, making it easier to work with the person; people who are more interactive with others; people who can eat without mouth pain and require less care; and pride among caregivers at seeing the people they work with become healthier with a happier smile.
Once the individual or caregiver understands the benefits of improved oral health for themselves and the person they care for, then they are more likely to be open to receiving additional information. At this point they can be provided with information about the difference between a healthy mouth and an unhealthy one, how to recognize oral health problems, and how to perform plaque removal techniques. These topics are all illustrated in the Overcoming Obstacles to Oral Health training materials described earlier (Glassman et al. 2011).
It is also important that any preventive program include an assessment of the individual’s risk for developing oral diseases and the use of a customized regimen of preventive medications. The Caries Management by Risk Assessment (CAMBRA) model is a system for determining risk of dental caries and providing targeted medications to alter the chemistry and environment of the mouth (Young et al. 2007). Particularly for dependent people, where it can be difficult to treat dental disease once it occurs, it is critical that prevention protocols include modern “medical” strategies incorporating medications such as fluoride in various forms, chlorhexidine, xylitol, buffering agents, and calcium phosphate replacement agents (Glassman 2003; Glassman et al. 2003). A detailed discussion of the indications for and use of these medications is beyond the scope of this chapter.
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