Dentistry for the Disabled Child and Adult

James E. Bubenik, DMD
Family Dentistry
8112 Delmar Boulevard
University City, MO 63130
(314) 725-7080
  Reprinted with the permission of the author

  1. Introduction
  2. Finding a Good Dentist for Your Disabled Child/Adult
  3. Levels of Anesthesia to Control Behavior
  4. Why Not Just Let the Baby Teeth Rot Away and Fix the Permanent Ones?
  5. Toothbrusing for Disabled People
  6. Bruxism (Grinding of the Teeth)
  7. Educational Materials
  8. Resources

I. Introduction

I have noticed many parents in and around St. Louis, MO have questions regarding dental care for children with disabilities. Some parents sound very concerned about this subject. I am very happy to share my knowledge.

I have been a full time practicing dentist in St. Louis, MO for 18 years and have an area of interest in special needs patients — mentally and physically disabled, behavior disordered, medical problems, dental phobics, etc. I have an extra year of training in hospital dentistry and am an assistant clinical professor at St. Louis University School of Medicine. I'm on the faculty of a dental residency training program at St. John's Mercy Hospital here in St. Louis. I am on staff at four local hospitals including Cardinal Glennon Children's Hospital. I feel most qualified to give advice and have put some of my thoughts below. Feel free to forward or repost this on any other lists but remember, these are just in-general comments and I would never intend this to apply to all disabled children and adults or to have it supersede what your own private dentist says after a thorough exam, radiographs and an individual diagnosis. All are my own opinions and are based on treatment of thousands of disabled patients of all descriptions.

II. Finding a Good Denstist for your Disabled Child/Adult

Your local branch of the American Dental Association (info below) is a good place to start. Ask for a dentist particularly skilled/experienced in treating disabled patients. This will probably be a general dentist or pediatric dentist. Don't be afraid to take your grown adult disabled children to a pediatric dentist. If your city has a dental school, call the department of Pediatric Dentistry, Community Dentistry or any Advanced Education Programs for general dentists. These are called AGD or GPR programs. SIU Edwardsville has an AGD program. I'd suggest not going with a regular dental student but seeking out the faculty member that teaches the students how to work on disabled patients. Many graduate (i.e. graduated dentist) students would probably be okay as a second choice. Ask for advice from some of the parents you meet who have older children with the same disability as your child. See how long they have been going. Ask what techniques the dentist uses and if they like the dentist. They'll feel honored that you asked them; we're all family. I totally agree with most other dentist's recommendations to start out on the right foot by making the first visits fun before they have cavities and pain. If the first visit you make is for relief of pain or infection and the child is scared, it is much more difficult for the dental team to avoid frightening your child even more.

III. Levels of Anesthesia to Control Behavior

Most severely disabled people need some type of special help to cooperate. For some, this is just knowing the dentist and having some level of trust that they won't be hurt or that any pain will be slight and will just last a few moments (i.e. a shot). For many others, this may be some diastraction such as headphones.

There is always a small portion of the Down syndrome population who is extremely phobic and will not cooperate ever, no matter what is done to establish trust. This group also includes very strong gaggers who cannot cooperate. A few people with Down syndrome fall into the severe or profound range of mental retardation and will never understand. Depending on the individual patient's needs, here is what I use in decreasing order of strength when patients don't know me or won't ever cooperate due to one of these causes:

  1. General anesthesia in a hospital as an in- or an out-patient: In the US now this is very safe and the anesthesia is usually kept at low levels for general dentistry. Oral surgeons can safely do general anesthesia in their offices. Anesthesiologists are better than nurse anesthetists. All anesthesia personnel are aware that special needs people present more risks than non-disabled people and they take this into consideration when they recommend anesthesia. If you are skeptical about this, discuss risks with them far in advance of the procedure. Call the hospital and make a special trip just to have your child prescreened by the anesthesiologist, if you are worried. We do.
  2. Intravenous sedation in the hospital or a private office: Many states require a special permit to do this. Your physician should give an H+P and an okay before this is done in a dentist's office, as an extra precaution. Down syndrome by itself is not a contraindication to intravenous sedation but some patients have heart or other problems that may be a factor.
  3. Nitrous oxide (laughing gas) and oral sedation together: This is safe for many patients as long as the oral medication is not given in too high a dose. In some rare instances dentists who do not have hospital privileges or a permit to do IV may be tempted to give a dose of oral medication that is too high. Ask your physician about the dose if you suspect this. Nitrous oxide is generally safe except in a few cases—those who don't or won't breath well through their noses (sometimes just temporarily due to nasal congestion), some types of asthma and in those who can't handle being 'high'. Remember, many people with Down syndrome cannot breathe well through their nose.
  4. Nitrous oxide or oral sedation by itself: See comments above.
  5. Psychological Techniques: Sorry to put this near the end, but in my experience this only works on mildly frightened patients. These techniques include systematic desensitization, tell-show-do technique, modeling good behavior (as by an older cooperative sibling), distraction and a host of other tricks. I have not tried hypnosis, acupuncture or biofeedback because I suspect that they won't work reliably in most patients.
    Electronic anesthesia (TENS unit, CEDETA dental unit, etc.) is not a very strong technique but may work in some cases as long as the disabled person is not the one controlling the unit (usually the patient IS allowed control the electricity if they are not disabled and understand the instructions).
  6. Local Anesthetic ('Novocaine') by Itself: Consider yourself lucky if this is all your dentist has to do. I find I can do this on only about 20% of my patients with disabilities due to a variety of reasons and that is only after they know me. If your dentist is now doing this with great success and doesn't need any other assistance with your disabled child, give him some cookies next Christmas.

Please do not go to a dentist that uses any of these techniques: Papoose board, hand-over-mouth technique (also called H.O.M.E.), scolding or restraints if the child is terrified. I think a papoose board is probably allright is the child needs it to help control involuntary movements but I feel it is cruel to use it against the child's will if he is scared and can't calm down. There are better techniques. Restraints are okay if the child simply needs reminders to keep hands away from mouth, etc. How do you know if these techniques are being used? Go in the operatory with the child and watch the procedure. If the dentist is uncomfortable or thinks your presence is making it harder to control the patient ("Mommy, come and rescue me from this strange person."), stand outside the operatory where the child can't see you. You can leave and wait in the reception room if you trust the dentist.

IV. Why Not Just Let the Baby Teeth Rot Away and Fix the Perminent Ones?

On the surface this seems sensible to harried parents who spend most of their energy/money on major medical problems, but it's a bad idea. Why? Baby teeth can get just as infected and abscessed as permanent (adult) teeth. Both children and disabled people of all descriptions tend to avoid telling parents when they have toothaches. A child with or without a disability who has a toothache, REALLY has a toothache.

V. Toothbrusing for Disabled People

All people with teeth need brushing. Brushing followed by flossing is better if possible. If your child will not let you near his mouth due to fear, unfamiliarity with the brush or tactile defensiveness around the face, here is how you systematically desensitize them: Start with just some wet gauze or a washcloth wrapped around your finger and move it around the lips until the child will accept this. Use a massaging motion. Put something sweet on it to give him extra incentive if needed. When he gets accustomed to this and seems to like it (this may take quite a few sessions), start to go inside the mouth. Back teeth seem to be less sensitive than the front ones on most tactile defensive people, so start on the back ones. Be patient. Don't worry if he clenches; you are making progress and he'll open later. When this has become routine, start putting the brush in the mouth to do the cleaning. If he doesn't like the bristles on the brush, just use the other end (the handle part) to desensitize him to the feel of that. Use a soft or ultrasoft bristle brush. Heat the bristles in hot water to soften them if needed, anything to get the child to take that first step. Stop if you are gagging him. Give him an old brush with something on it to make it taste good and let him play with it and chew on it by himself before or after the toothbrushing session. Expect that this systematic desensitization program will take several weeks but it is well worth the effort. Do it at the same time and in the same place every day. Give him/her a reward after the session is over.

Mechanical (electric or sonic) toothbrushes are allright only if your child will accept something like this in the mouth and they have learned to accept a regular brush first. Use toothpaste sooner or later in this series of steps but remember it is supposed to feel and taste good, so don't use anything that will turn your child off. The only real value of toothpaste is the fluoride in it. Use only a pea-sized drop of toothpaste. My all-time favorite flavor of toothpaste for kids is Oral-B Bubble Gum Flavor. Use water or fluoride rinse if they won't use toothpaste. Don't feel bad if your child never gets accustomed to toothpaste, it is not 100% essential.

Some good positions for doing all of this cleaning are shown in the ADA brochure mentioned below titled Dental Care for Special People. Most people with significant physical or mental disabilities need someone else to brush and floss their teeth for them. This may sound funny to you but I thoroughly recommend it after seeing many disabled people show dramatic improvement in dental health when a competent person takes over this part of their self-care.

VI. Bruxism (Grinding of the Teeth)

Bruxism (grinding of the teeth) can come from many things ranging from anxiety to malocclusion of the teeth. It is important to determine whether the grinding is secondary to something else. If the cause of the bruxism is something bad for the child in other ways, such as chronic pain or anxiety, it is of course important to get to that problem first. (The pain I am talking about here would be somewhere else in the body; not the teeth.)

If the grinding is caused by malocclusion of the teeth, a professional will have to determine if straightening or some other treatment is needed. Not many disabled people get orthodontics but I think that may be just traditional. There is usually no reason not to do it if they are cooperative. Other treatments such as equilibration of the teeth or a bite guarding splint can be made if the bruxism is indeed causing problems or if it is a symptom of another problem such as TMJ dysfunction.

The good news is that in most children, plain grinding by itself does not cause any permanent harm, other than to change the looks of the teeth. It does not cause cavities or any other problem to crop up as long as the mouth is kept clean. It can sound bad especially if they do it all the time or at night when they sleep but I feel it is just one of those things that the rest of the world has to get used to in the disabled population because I don't think the disabled population is going to change to conform to the expectations of the rest of the world. (Sweatshirt noticed at a Down Syndrome convention: "The problem is not the way I look, but the way you see me.")

VII. Educational Materials

Single copies of the following brochures are available at no charge by sending a stamped self-addressed business size envelope for each brochure to:

ADA Home Page
American Dental Association
Department of Public Information and Education
211 East Chicago Avenue
Chicago, IL 60611
(312) 440-2500
Recommended Brochures: * Pit and Fissure Sealants are highly recommended on all undecayed posterior teeth for just about all disabled people due to the high success rate of sealants in preventing cavities.

VIII. Resources

American Dental Association
211 East Chicago Avenue
Chicago, IL 60611
(312) 440-2550
Fax: (312) 440-2800

Academy of Dentistry for the Handicapped
211 East Chicago Avenue
Chicago, IL 60611
(312) 440-2660

American Academy of Pediatric Dentistry
211 East Chicago Avenue #1036
Chicago, IL 60611
(312) 337-2169

National Foundation of Dentistry for the Handicapped
1600 Stout Street, Suite 1420
Denver, CO 80202
(303) 573-0264

The Grottoes of North American Dentistry for the Handicapped
34 N. Fourth Street
Columbus, OH 43215
(614) 463-9193

If you contact any of these for a referral, they will probably only be able to refer you to their own members. The first three have lots of members, the last two are smaller groups.