Care of the teeth of people with an intellectual disability
Everyone benefits from a healthy mouth. With a healthy mouth you can eat and drink well. A fresh mouth also looks nice. People with an intellectual disability are more likely to have problems in their mouth. The motor skills are often weak or completely limited. In the mouth this manifests itself, for example, in weak lip, tongue and cheek muscles. But a different tooth position, muscle tensions, tooth damage due to falls or bumps (epilepsy) or nutrition can also cause difficulties in the mouth. With good oral care you keep the teeth and gums of your child or client healthy. Different mouth problems are associated with different ages. Whether you brush the teeth of a child or an adult with an intellectual disability, you will encounter dilemmas to a greater or lesser extent. Here you can read the most common problems and provide solutions for good oral care.
Dental plaque and holes
Dental plaque is a white-yellow layer that is hard to see. It arises on and between the teeth and molars and on the transition to the gums. There are bacteria in plaque. These bacteria convert carbohydrates, such as sugar and starch from food and drinks, into acids in the mouth. These acids cause cavities (caries) in the teeth.
Dental plaque and inflamed gums
Healthy gums are pink, lie tightly around the teeth and molars and do not bleed when the teeth are brushed. Red, swollen or bleeding gums usually indicate inflamed gums. If you do not remove the plaque on and between the teeth properly, the bacteria in the plaque will cause the gums to become inflamed. Non-removed plaque can become hard and turn into tartar. New dental plaque easily adheres to tartar. This way the gums become more and more inflamed. The inflammation can even affect the underlying jaw bone. Severe gum problems can lead to tooth loss.
Gaps and gum disease are infectious diseases with consequences for both oral health and general health.
How do you remove the plaque?
Brushing your teeth is the basis of good oral hygiene. It is a precise job and certainly not easy. Brushing your teeth is probably too difficult for your child or client. Your help is needed for this. But many children or clients often turn their heads away or push the brush away with their tongue. For example, they bite the brush, gagging, have tight cheeks, lips and tongue, clench their jaws, have severe bleeding gums and pain reactions, or resist in some other way. A good posture and the right aids make it easier for your child or client to brush your teeth. Brush the teeth carefully twice a day and not too forcefully. Use the cleaning instruction for this. A good cleaning takes two minutes. So take your time! Choose a moment on the day that you can pay attention to oral care for your child or client, preferably in the morning after breakfast and in the evening before bed.
Dentistry book recommends brushing your teeth for two minutes twice a day, but realizes that this is not feasible in all situations. Brushing your teeth carefully once a day is better than twice a day. Ask your dentist or dental hygienist for other tips and advice to brush your child's or client's teeth.
Choose a good toothbrush
Opt for an electric toothbrush with a small brush head. With proper use, electric toothbrushes remove more plaque than manual toothbrushes. Your child or client must get used to brushing with an electric toothbrush. Take two weeks for this. Are you still unable to brush electrically after that period? Then choose a manual toothbrush with soft hair and a small brush head. The teeth of adults can also be brushed with a child's brush if this reduces resistance in your adult child or client. The following applies to all brushes: replace the toothbrush every three months or if the tufts start to separate.
Use fluoride toothpaste
Fluoride makes tooth enamel stronger and less soluble in acid. Therefore, use a toothpaste with fluoride. You can brush with fluoride toothpaste even if your child or client cannot rinse after brushing. Swallowing a small amount of toothpaste is not a problem. Sometimes it can be useful without brushing toothpaste. Then, after brushing, spread some fluoride toothpaste on your teeth with your finger. This way you still apply fluoride to the teeth.
The basic fluoride advice is:
- 0 and 1 year, starting with the first teeth: brushing once a day with fluoride toothpaste
- 2, 3 and 4 years: brush twice a day with fluoride toothpaste
- 5 years and older: brush twice a day with fluoride toothpaste
- For all ages: all other forms of fluoride use in consultation with a dentist or dental hygienist
Your dentist or dental hygienist may advise you to use extra fluoride for your child or client.
Use a toothpick or brush between the teeth
With a toothbrush alone you cannot properly clean the spaces between the teeth. This applies to both a manual toothbrush and an electric toothbrush. Therefore, use a toothpick or brush for the spaces in between. A good toothpick is made of wood, triangular in shape with a flat side and ends in a point. They can differ in thickness. You can use thicker stokers for larger spaces. For narrower spaces, choose a thinner variant. Ragers are also available in all shapes and sizes. Use a toothpick or brush once a day if possible. Choose a suitable moment yourself, for example in the afternoon when it is a bit quieter. Ask your dentist or dental hygienist which toothpick or brush can best be used with your child or client and ask for an instruction. See also the instruction in this brochure.
And if brushing fails?
Sometimes it is not possible to use a toothbrush. A gauze pad or a finger toothbrush with fluoride toothpaste can be practical substitutes. If this form of brushing your teeth is also not possible, a rinse aid or mouth spray based on chlorhexidine can offer a solution. This substance reduces the effect of harmful bacteria in the dental plaque. Always consult your dentist or dental hygienist before use and ask for an instruction. This is because the teeth can discolour due to the use of a chlorhexidine agent.
To the dentist or dental hygienist
Take your child or client to the dentist or dental hygienist at least twice a year. The teeth are then properly checked and you receive guidance to keep your mouth healthy. Far-reaching treatments can thus be prevented. Is there pain? Stop delaying a visit and make an appointment. The dentist or dental hygienist can also indicate that he wants to increase the frequency of the visit for your child or client. Not all dentists are experienced in treating people with disabilities. For example, they will refer to a colleague or to a Center for Special Dentistry. You can get in touch with such a center through the Association for the Promotion of Dental Health Care for the Disabled (VBTGG) and the Central Consultation of Special Dentistry (Cobijt). You need a referral letter from your home dentist
Instruction correct cleaning attitude for people with intellectual disabilities
Proper cleaning attitude
A correct brushing attitude is more important than you may think. Too often parents or guardians stand before their child or client. But then you have little vision in your mouth, you have no control over your child or client and you yourself are in a vulnerable position. Have your child or client sit down and stand diagonally behind him. Fix the head and look in the mouth what you are doing. Press the cheek with your finger into the mouth of your child or client and push the lip away with your thumb. Is your child or client lying? Then choose his or her preferred attitude. For example, raise the head slightly with the help of a rolled-up towel in his or her neck. For children and clients with a swallowing disorder, brushing your teeth can increase the risk of choking. Brushing your teeth can also induce a gag reflex. Brush their teeth without toothpaste. After brushing, apply a little fluoride toothpaste to your finger and "lubricate" the teeth and choose them. Use an (electric) toothbrush and a toothpick or brush. Clients are advised to wear gloves for hygiene reasons.
Opening the mouth
If your child or client is unable or unwilling to open their mouth, arrange for a mouth check. Bend the head slightly forward. This makes the mouth easier to relax. There are two ways: mouth check from the front (see photo) and from the side.
Mouth check from the front
Place your thumb of your left hand (for the left hand the other hand) on the chin pad, your index finger on the cheek and your middle finger under the chin. Make sure your thumb does not touch the lower lip. Press gently on the chin pad with your thumb and gently up with your middle finger. The mouth opens.
Mouth check from the side
Place your index and middle fingers of your left hand (for left-handed people the other hand) around the chin. Place your index finger on the cushion of the chin, your middle finger stretched out under it. Make sure your index finger does not touch the lower lip. Your thumb rests on your hand, not on the face. Using your index finger, gently press the chin pad and gently lift your middle finger up. The mouth opens. Ask your dentist or dental hygienist for a demonstration.
If it is very difficult to keep your mouth open, bitwoods and cubes as used by the dentist can sometimes help. There are biting wood and blocks (made of rubber and) made of steamed beech wood. They do not give sharp splinters, even if they are chewed. You can get them through your dentist or dental hygienist. You can also ask them for advice about their use.
Mouth problems in people with intellectual disabilities
People with intellectual disability are more likely to have gum disease and tooth decay (cavities). This has a number of reasons:
Due to chewing and swallowing problems, people with intellectual disabilities often eat liquid, pureed or finely chopped, soft (probe) food. They also often keep food in the mouth for a long time. Soft food reduces the natural self-cleaning action of the mouth. Consumption of soft (probe) food promotes the formation of dental plaque. Once hardened dental plaque becomes tartar. New plaque easily sticks to tartar again.
What to do with a soft diet
Oral hygiene is the key word here. Make sure you remove all plaque daily to prevent cavities and gum disease.
Reduced natural mouth cleansing
Not only soft food causes a reduced self-cleaning of the mouth. Stiff and weak paralysis of the mouth muscles, constant opening of the mouth and mouth breathing are also causes of reduced natural cleansing of the mouth.
What to do with reduced natural mouth cleansing
Here also applies: oral hygiene. Make sure you remove all plaque daily to prevent cavities and gum disease.
Often sucking on a baby bottle or anti-spill cup with sweet content, for example fruit juice, syrup, drinking yogurt and other milk products, can affect the teeth. Because the teeth come into contact with sugars for a long time, there is a high risk of developing so-called baby bottle caries.
What to do when sucking
Limit the amount of sweet drinks. As an alternative, give water or regular tea without sugar if possible. Have your child or client drink sweet drinks one after the other. If possible, use a normal cup, for example with a straw. In the evenings and at night, drinking from a baby bottle with sweet content is extra harmful. At night, the saliva can hardly restore the acid attacks on the teeth. Drinking water from a baby bottle (at night) is not harmful.
Reflux and ruminating food
Heartburn is extremely acidic. Acids that enter the mouth damage the tooth enamel. This form of irreversible dental wear is called dental erosion. Some clients bring the stomach contents back into the mouth (ruminating or ruminating) or suffer from spontaneous return of food (reflux). In reflux, stomach acid flows back into the esophagus and into the oral cavity as a result of a malfunction of the sphincter between the esophagus and the stomach.
What to do in the event of reflux or ruminating
Acid-inhibiting medicines can offer a solution. Sometimes reflux surgery may be necessary. Adjusting the diet can also have an effect. For dietary advice, contact the dietician.
Disorder in the switch order
Children are usually born toothless. A child changes his milk teeth between the ages of six and twelve. That is at least in "the booklets". The change period may be different for your child or client. Children with intellectual disabilities often have a small jaw. Because of this the teeth will not fit. Often a child does not change all his teeth, but partially, while the permanent teeth are laid. The times when the teeth come through can also deviate.
What to do when changing
The enamel of the newly broken teeth and molars is still very porous and vulnerable. Brush the dots of the new teeth or choose immediately as soon as they have broken through. When new teeth come through, the gums often swell. That is normal. It can be painful, but you don't have to worry. Visit the dentist regularly for a check-up.
Deviating tooth position
Many people with an intellectual disability have a deviation in the position, shape and number of teeth. If teeth are neatly arranged, you can clean them well. It becomes much more difficult if they stand behind and behind each other. It is difficult to reach with the brush. A deviating tooth position usually has no consequences for the health of the teeth.
What to do with a different tooth position
Extra attention to oral hygiene. Pay particular attention to the spaces between the teeth. Sometimes the dentist can improve a different tooth position with a brace or with implants, for example. The dentist can also advise you to shorten the dental arch (choose to pull) so that brushing your teeth becomes easier.
Use of medication
Various medications have the side-effect that the salivary glands are inhibited in the release of saliva. These are mainly medicines used to treat high blood pressure (anti-hypertensive drugs), cardiac arrhythmias (digoxin, anti-arrhythmics) or medicines such as antidepressants, sleeping pills and urinary drugs. The drugs usually do not affect the salivary glands themselves, but only inhibit saliva release. Saliva has a lubricating effect when talking, chewing and swallowing. With the help of saliva we can move more easily with our cheeks, tongue and lips. With saliva we moisten our food in such a way that we can swallow it painlessly. Saliva also moisturizes the oral mucosa, preventing dehydration. Moreover, it has a cleansing effect on teeth, molars and the oral mucosa. In addition, saliva inhibits the functioning and growth of bacteria and fungi in the mouth, preventing mouth infections. If your child or client has insufficient saliva, plaque will form faster than normal. This creates holes faster. This happens especially when your child or client regularly eats or drinks sugar-containing food. In a dry mouth the formation of plaque and cavities mainly occur along the edges of the gums. This can also cause the gums to become inflamed. Use of medication can also have other consequences, such as gum growth (anti-epileptic medicines), discolouration of the teeth (chlorhexidine) and the production of too much saliva, so salivation (analgesics, antipsychotics, anti-stroke agents).
What to do with a dry mouth
If medication is the cause of your child's or client's dry mouth, consult your doctor or specialist to see if you can adjust the type of medication, dosage or time of administration. You can stimulate the saliva production of your child or client by giving him food that he should chew properly. Consider firm brown sandwiches, carrots or sugar-free chewing gum. The release of saliva can also be enhanced by eating slightly acidic foods, such as fruit or cucumber. This often does not work or does not work well enough for people who have been suffering from Sjögren's syndrome for some time or who have been irradiated in the head or neck.
What to do with gum growth
Tell the dentist or dental hygienist that your child or client has started taking the medication. Immediately from the start extra good oral hygiene is important. Then you can prevent gum growth in your child or client. The gums grow mainly in places where there is plaque. Removing the plaque is therefore extra important. Certainly because brushing away in those places is becoming increasingly difficult. Red, swollen and bleeding gums are inflamed. The inflammation never goes away by itself. Good oral hygiene is extra important. Visit the dentist or dental hygienist regularly to have your child or client's mouth cleaned.
What to do when drooling
By eating sugar-containing food, saliva production increases. Therefore give your child or client as little as possible. Close your child's or client's mouth as much as possible. In the event of persistent complaints, contact your doctor, dentist or speech therapist.
Children and adults with epilepsy may fall at an unexpected time. Someone who falls on his face has a chance of breaking or losing his teeth. People with reduced mobility, or who are otherwise restricted by motor, are often more unstable and therefore have a greater risk of tooth injury. Then there is a group of patients who harm themselves. They suffer from automutilation. Automutilation can lead to tooth injury.
What to do with tooth injury
If the tooth has broken off, is loose or is out of the mouth: go to the dentist immediately. Keep (the broken part of) the tooth wet in milk.
Thumbing in a mouth with permanent teeth is bad for the position of the teeth. Sucking on cloths, teats and fingers can also lead to a different tooth position. People with intellectual disabilities often suck extremely, which changes the tooth position. An abnormal tooth position can make oral hygiene more difficult. But nail biting and grinding teeth (bruxism) also increase the risk of dental wear.
What to do with wrong habits
Try to learn the deviating habits of your child or client. Encourage positive behavior. Ask your dentist, dental hygienist, speech therapist or remedial educationalist for advice.
People with Down syndrome often have weak tongue and mouth muscles. They make it more difficult to swallow, eat, drink and speak. This makes the self-cleaning function of the mouth less effective. The result is more dental plaque. People with Down breathe more through the mouth. A dry mouth is then the result. As a result, the protective effect of the saliva is limited. Due to the reduced resistance, these people are more likely to develop severe (gum) infections. Moreover, the roots of teeth and molars of people with Down are often short. In the case of gum disease, they can therefore stand loose sooner.
What to do with Down syndrome
Promote good mouth habits. Teach your child or client to hold the tongue in the right place as much as possible, so as much as possible behind the front teeth. Start early with this. Proper use of the tongue stimulates you more with breastfeeding than with bottle feeding. A speech therapist can give you explanations and exercises for the correct use of the tongue. Try to promote breathing through the nose of your child or client. You can do that by consistently closing your mouth when your child or client is sleeping.
Cleaning of prostheses and implants in people with intellectual disabilities
Many adults with a mental disability wear a dental prosthesis. These days, treatment with implants is also possible for people with intellectual disabilities. An implant is a type of artificial root that is screwed into the jaw on which the dentist can attach a crown (tooth or molar), bridge (more teeth or molars) or prosthesis (dentures). In both situations, good oral hygiene is very important to prevent infections and inflammations.
Cleaning the prosthesis
Just like your own teeth and molars, you must thoroughly clean your client's prosthesis on a daily basis. If you do not clean your dentures regularly, food residues will remain. Both on the dentures and underneath. If you do not remove it, the gums can start to become inflamed. Preferably, rinse the prosthesis and mouth with water after each meal. Remove food scraps on the prosthesis and in the mouth. Use a special prosthesis brush, for example from Lactona or Oral-B, to thoroughly brush the prosthesis and thereby remove plaque. Do not use toothpaste for this. It can sand too much. Use water and a mild liquid soap. A clean denture always feels smooth. Do not let the smooth teeth slip out of your hands during cleaning. It will break. Just to be sure, first fill the sink with water and clean the dentures above it.
Put the dentures in vinegar once a week. This prevents the formation of tartar on the dentures. Then brush the dentures well and rinse with water. Never place the dentures in hot water and certainly do not use bleach or abrasives. If necessary, ask your client's practitioner for advice.
Also clean your client's mouth
In addition to the prosthesis, also clean the mucous membrane on which the dentures are resting: the jaws, the palate and the transition from the jaw to the cheeks. Otherwise, annoying inflammations can occur. And now it also applies: prevention is better than cure. Massage the mucous membrane at least once a day with a soft toothbrush and water. Pay extra attention to the palate. Always start from the outside in the upper jaw. Your child or client gets used to it the easiest and gives the least resistance. Always push the brush up a little. Then polish the inside of the upper jaw. Then brush the outside of the lower jaw, followed by the inside of the lower jaw. When your child or client catches quickly, it is best to brush from the center to the side and back. Also read the information about the correct brushing posture and methods to open the mouth.
Remove the dentures at night
At night you have to put the prosthesis out of your child or client's mouth to keep the mucous membrane on which the prosthesis rests healthy. After cleaning, store the prosthesis in a bowl of clean water. Brush the prosthesis again in the morning before placing it back in the mouth of your child or client.
There are various prosthetic cleaning products on the market. The hydrogen peroxide that is in it has an antibacterial effect. A cleaning agent inhibits or removes discolouration of coffee, tea, wine and tobacco, among other things, and is refreshing. A cleaning agent does not dissolve dental plaque. This requires brushing. Excessive use of these cleaning agents can damage the prosthesis. The dentures can fade and the surface can become rougher. A prosthetic cleansing tablet can be life threatening for your child or client. Damage to the esophagus can also occur if your child or client sees the tablet as a candy. It is therefore recommended to use water and liquid soap daily and vinegar once a week.
An implant under a crown or bridge is anchored in the bone. It is very important that you thoroughly clean the transition from the crown or bridge to the gums. Carefully brush this area with a soft (electric) toothbrush with fluoride toothpaste and use toothpicks or brushes. Oral hygiene is very important with implants, also for people with disabilities. Poor oral hygiene can cause your child or client to lose their implant.
You can clean implants that serve as pillars under a canopy prosthesis with a soft toothbrush and toothpaste, brushes and / or (super) floss thread. Brush the part of the implant that protrudes above the gums twice a day. Pay extra attention to the transition from the implant to the gums. Clean the area under the splint with brushes and / or superfloss as directed by the dentist or dental hygienist. On the instructions of the dentist or dental hygienist you can apply chlorhexidine gel once a day around the implant and place the dental prosthesis over it.
If you do not remove food residues and plaque around the implants, the gums will become inflamed. As a result, they eventually lose their hold, they stand loose and can cause pain. Also view the correct brushing posture, mouth opening methods and brushing instruction.