Medical Article Oral health Article is attached This is an academic, professionally written exercise consisting of a minimum of 3 to 4 paragraphs in len

Medical Article Oral health Article is attached

This is an academic, professionally written exercise consisting of a minimum of 3 to 4 paragraphs in len

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This is an academic, professionally written exercise consisting of a minimum of 3 to 4 paragraphs in length. 

Each paragraph to contain of a minimum of 4 to 5 sentences.

To consist of 750 to 1000 words. (No Less no more.)

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CONCLUSION: Conclude with what you learned from analyzing the article. What knowledge was gained from reading this article? What do the results cited in the article indicate? Do not present new or additional information in the conclusion, stay focused on the article topic at hand. “After reading and analyzing this article I learned that …. “ 

| PEER-RE VI E WED |evidence & practice / CPD / mouth care

Aims and intended learning outcomes
This article aims to provide information
for nurses and other healthcare
professionals on evidence-based practice
to support people with intellectual
disabilities with their oral healthcare
needs and access to dental services.
Such knowledge is essential to enhance
the oral health of this population. The
article emphasises the importance of
nurses being aware of the latest evidence
about oral healthcare interventions for

people with intellectual disabilities and
explains how this should inform their
practice. After reading this article and
completing the time out activities you
should be able to:
» Evaluate knowledge of oral healthcare
that can be applied to evidence-based
practice and supports people with
intellectual disabilities.
» Recognise the oral healthcare needs
that people with intellectual disabilities
commonly experience.

Citation
Hartnett L, McNamara M
(2021) Oral health and
supporting people with
intellectual disabilities to
get access to dental
treatment. Learning
Disability Practice.
doi: 10.7748/ldp.2021.e2123

Peer review
This article has been
subject to external
double-blind peer review
and checked for plagiarism
using automated software

Correspondence
liz.hartnett@dcu.ie

Conflict of interest
None declared

Accepted
4 November 2020

Published online
February 2021

Why you should read this article:
● To improve your knowledge of the barriers that people with intellectual disabilities experience when
accessing dental services
● To understand how to support people with intellectual disabilities with their oral healthcare
● To familiarise yourself with latest evidence about optimal practice in oral healthcare for people
with intellectual disabilities

Oral health and supporting people
with intellectual disabilities
to get access to dental treatment
Liz Hartnett and Martin McNamara

Abstract
Oral health is an important aspect of a person’s overall health and well-being. People with
intellectual disabilities have poorer oral health than the general population, so it is essential that
service users and their carers are supported to address this. This article provides information
for nurses and other healthcare professionals on how to provide evidence-based practice
that supports people with intellectual disabilities with their oral healthcare and assists them to
access dental services. The authors examine the latest evidence about optimal practice in oral
healthcare for people with intellectual disabilities, emphasising the importance of a person-
centred approach. The article also discusses the barriers that people with intellectual disabilities
experience when accessing dental services and how these barriers can be addressed.

Author details
Liz Hartnett, lecturer, School of Nursing, Psychotherapy and Community Health, Dublin City
University, Dublin, Republic of Ireland; Martin McNamara, professor, School of Nursing Midwifery
and Health Sciences, University College Dublin, Dublin, Republic of Ireland

Keywords
clinical guidelines, evidence-based practice, learning disability, nursing care, oral health,
oral hygiene, professional

learningdisabilitypractice.com volume 24 number 2 / April 2021 / 3 3

Permission
To reuse this article or for
information about reprints
and permissions, contact
permissions@rcni.com

| PEER-RE VI E WED |evidence & practice / CPD / mouth care

» Understand the importance of a person-
centred approach when supporting
people with intellectual disabilities with
their oral healthcare needs.
» Identify the issues that people with
intellectual disabilities may experience
when accessing oral healthcare support
and dental services.
» Outline evidence-based guidance on
making oral healthcare and dental
services increasingly accessible to people
with intellectual disabilities.

Introduction
It has been identified that people with
intellectual disabilities have poorer
oral health than the general population
(Wilson et al 2018). For example, Anders
and Davis’ (2010) systematic review
revealed higher levels of dental caries
and periodontal disease in people with
intellectual disabilities compared with
the general population. Similarly, Public
Health England (PHE) (2019) guidance
also recognises that this group has greater
unmet oral healthcare needs and reduced
access to dental services compared with the
general population. Oral healthcare can
affect a person’s overall health and well-
being (Waldron et al 2019), so it is essential
that people with intellectual disabilities
receive the necessary support.

Knowledge to support
evidence-based practice
To support people with intellectual
disabilities with their oral healthcare
needs effectively, it is important that
nurses can access and appraise knowledge
that can be applied to evidence-based
practice. One of the themes of The
Code: Professional Standards of Practice
and Behaviour for Nurses, Midwives
and Nursing Associates (Nursing and
Midwifery Council (NMC) 2018) is to
practise effectively, and this involves nurses
using evidence to support their practice.
Continuous development of the evidence
base through research is important to
enable nurses to select the most relevant

and up-to-date knowledge to ensure that
their practice is effective.

Another theme of the Code (NMC 2018)
is to promote professionalism and trust,
which includes the requirement for nurses
to keep their knowledge and skills up to
date. An important aspect of this is the
development of the profession’s knowledge
base, which is vital in providing evidence
for clinical practice. Young (2013) asserted
that specialised knowledge is at the core of
any professional group. This article focuses
on the development of the specialised
knowledge required to support people
with intellectual disabilities with their oral
healthcare needs and to facilitate their
access to dental services.

Oral healthcare needs
Evidence from several studies has indicated
that this population has higher levels of
untreated tooth decay compared with the
general population (Anders and Davis
2010, Wilson et al 2018). Mac Giolla
Phadraig et al (2015a) found that people
with intellectual disabilities are more likely
to have teeth extracted than restored and
that about one third of those aged over
50 years did not have any teeth or dentures.
Anders and Davis (2010) also identified that
people with Down’s syndrome may have
suboptimal oral health. In addition, people
with intellectual disabilities often have low
awareness of oral health issues, and may rely
on others to assist with their oral healthcare
and to arrange dental appointments
(Cumella et al 2000, PHE 2019).

Box 1 lists some of the common
oral health issues in people with
intellectual disabilities.

Suboptimal oral health
Oral health affects a person’s overall health
status, and experiencing oral health issues
can affect all areas of their life (PHE 2019).
Suboptimal oral health may cause pain,
potentially leading to serious issues for
some people with intellectual disabilities
who have difficulty communicating their
pain (PHE 2019). Suboptimal oral health

Key points
● It has been identified
that people with
intellectual disabilities
have poorer oral health
than the general
population

● People with intellectual
disabilities often have
little awareness of oral
health issues, and may
rely on others to assist
them with their oral
healthcare

● One significant
barrier to effective
oral healthcare in this
population is a lack
of specific training
for dentists

● Oral healthcare
delivered using a
person-centred
approach has an
essential role in
improving the overall
well-being of people
with intellectual
disabilities

learningdisabilitypractice.com3 4 / April 2021 / volume 24 number 2

| PEER-RE VIE WED |

has also been associated with cardiac
disease, aspiration pneumonia, diabetes
mellitus and stroke (Wilson et al 2018,
Ward et al 2019). It may also have
a negative effect on an individual’s self-
esteem, communication and ability to
socialise (PHE 2019). In addition, having
no teeth limits a person’s food choices, has
a negative effect on their ability to chew
and on their nutritional intake, and can be
associated with obesity (Davies et al 2008,
Wilson et al 2018). Oral health issues
can also diminish a person’s enjoyment of
eating (PHE 2019).

Evidence suggests that people with
intellectual disabilities often have additional
risk factors for suboptimal oral health,
some of which are detailed in Box 2.

Reasonable adjustments need to be made
to address the barriers that people with
intellectual disabilities may experience
when accessing dental services (PHE
2019). Considering the risk factors and
barriers to dental services, as well as the
evidence relating to suboptimal oral health,
it is crucial that people with intellectual
disabilities are supported with this aspect
of their care and facilitated to access
dental services. However, Mac Giolla
Phadraig et al (2013) found that healthcare
staff supporting people with intellectual
disabilities often do not have the
knowledge and skills required to provide
effective oral healthcare.

Mac Giolla Phadraig et al (2018) analysed
data from a cross-sectional survey of
adults with intellectual disability who were
aged over 40 years. They identified that
many people with intellectual disabilities
find it challenging to cope with the dental
treatment that they require and may have
difficulties in expressive communication,
which can lead to behaviours that challenge.

Gum disease and dental decay are the
most common oral diseases and can lead
to the loss of teeth and oral functional
impairment (Mac Giolla Phaidraig et al
2015b, 2018). Oral healthcare and dental
treatment can prevent or manage these
conditions. However, it has been identified

that people with intellectual disabilities
in the Republic of Ireland have poorer
outcomes in relation to gum disease and
dental decay than the general population
(Mac Giolla Phadraig et al 2015b), as well
as a higher incidence of untreated dental
caries and periodontal disease (Anders
and Davis 2010). Furthermore, oral health
issues in people with intellectual disabilities
can be more complex than in the general
population (Wilson et al 2018). Therefore,
it is important that existing evidence is
disseminated among nurses and other
healthcare professionals, and that further
research is undertaken to generate evidence
on what interventions are most effective
for this group to improve their oral
health outcomes.

Evidence in relation to oral health
interventions
Wilson et al (2018) emphasised that further
research is required to improve healthcare
professionals’ understanding of effective

Box 1. Common oral health issues in people with intellectual
disabilities

» Greater incidence of gum inflammation
» Reduced preventive dentistry
» Increased plaque levels
» Untreated tooth decay
» Greater use of extraction rather than restorative interventions
» Increased rates of toothlessness
» Greater numbers of missing teeth, no teeth and no dentures
» Reliance on others for oral health care
» Low awareness of oral health issues

(Adapted from Anders and Davis 2010, Mac Giolla Phadraig et al 2015b, Wilson et al 2018, Public Health
England 2019)

Box 2. Risk factors for suboptimal oral health in people
with intellectual disabilities

» Medicines that reduce saliva flow, for example antidepressants
» Medicines that increase gum inflammation, for example some anticonvulsants
» Enteral feeding
» Gastroesophageal reflux disease
» Issues with accessing dental services
» Lack of understanding of the need for daily oral health care
» Lower income and education levels
» Dexterity issues that may hinder an individual’s tooth-brushing abilities

(Adapted from Davies et al 2008, Anders and Davis 2010, Wilson et al 2018, Public Health England 2019,
Joint Formulary Committee 2020)

Online archive
For related information,
visit learningdisability
practice.com and search
using the keywords

learningdisabilitypractice.com volume 24 number 2 / April 2021 / 3 5

| PEER-RE VI E WED |evidence & practice / CPD / mouth care

oral healthcare interventions for people
with intellectual disabilities, since each
person will experience different challenges
in relation to their oral care needs. Further
research is necessary to develop existing
knowledge and understand its application
to nursing practice (Waldron et al 2019).

Wilson et al (2019) conducted
a systematic review to collate the existing
evidence and identify interventions that
improve oral health outcomes for people
with intellectual disabilities. They found
that one intervention that could improve
care for this population was education
for healthcare professionals on providing
oral healthcare support. The provision of
outreach oral health services to support
access to dental services has also been
shown to have positive effects on oral
health (Wilson et al 2018). In addition,
the use of general anaesthesia to facilitate
dental treatment was considered to
increase the efficacy of treatments for
some people with severe and profound
intellectual disabilities or with dental-
related behaviours that challenge. However,
further research is required in relation to
the use of specific tooth-brushing methods
to improve oral health, since existing
outcome findings remain uncertain.

Wilson et al’s (2019) systematic review
identified that a uniform approach to
supporting oral health in this population
is not recommended. Instead, there is
a need for an approach that acknowledges
the diverse needs of people with
intellectual disabilities, their carers and the
service context.

Waldron et al (2019) reviewed the
effectiveness of oral hygiene programmes
for people with intellectual disability,
concluding that the evidence relating to
the benefits of these programmes for this
population remains unclear. They identified
that there is a need for further research
to evaluate interventions and stated that
studies with increased sample sizes could
add to the evidence base. Waldron et al
(2019) also emphasised the importance of
developing research that focuses on the

effects of suboptimal oral health on overall
health and quality of life of people with
intellectual disabilities.

Evidence-based oral health interventions
for people with intellectual disabilities
include (Wilson et al 2018, 2019, PHE
2019, Waldron et al 2019):
» The provision of outreach oral health
services to support improved access to
oral health services.
» General anaesthesia to facilitate dental
treatment for some people with severe
and profound intellectual disabilities
or with dental-related behaviours
that challenge.
» Approaches where the diverse needs
of people with intellectual disabilities,
their carers and the service context are
acknowledged and addressed.

TIME OUT 1
Read the following documents:
» PHE (2019) Oral Care and People with Learning
Disabilities guidance
» Faculty of Dental Surgery, The Royal College of
Surgeons of England (2021) Clinical Guidelines and
Integrated Care Pathways for the Oral Health Care
of People with Learning Disabilities

How could these documents inform your practice in
supporting people with intellectual disabilities with
their oral health?

Waldron et al (2019) recommended that,
given the uncertainty about the evidence for
the clinical effectiveness of oral healthcare
interventions, high-quality randomised
controlled trials are needed to clarify and
develop the findings in their review. In
the absence of such studies, Waldron et al
(2019) recommended the use of professional
expertise and emphasised that oral
healthcare should be based on the individual
needs of the person and their carers.

Taking a person-centred approach
One theme of the Code (NMC 2018) is
to prioritise people, and taking a person-
centred approach to oral healthcare is
consistent with this. The issues that people
with intellectual disabilities experience in

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| PEER-RE VIE WED |

relation to their oral health are specific
to each individual (Wilson et al 2018);
therefore, nurses should ensure that they
understand how to take a person-centred
approach to their care.

Some individuals with intellectual
disabilities experience challenges because
of sensory sensitivities, such as feeling
uncomfortable when encountering the
clinical smell of a dental practice; others
have risk factors, such as reliance on enteral
feeding. In addition, some individuals may
be afraid of attending dental appointments
or be anxious about any change in their
normal daily routine that is required
to address their oral healthcare needs.
Some people may display behaviours
that challenge or may have limited ways
in which to express themselves. Support
for the individual also needs to take into
consideration the service context and
carers’ particular characteristics and needs
(Waldron et al 2019), as well as the barriers
that each person experiences in accessing
dental services.

The Code (NMC 2018) specifies that
nurses need to listen and respond to the
choices of each individual and respect their
diversity. It also states that nurses must listen
to the person’s individual preferences and
concerns and that they should be involved
in any decisions about their care. Similarly,
the Nursing and Midwifery Board of Ireland
(2014) Code of Professional Conduct and
Ethics for Registered Nurses and Registered
Midwives details the need for nurses to
‘respect each person as a unique individual’
and emphasises the need to provide the
person with support and time to make their
own choices and decisions.

Many people with intellectual disabilities
can become anxious and upset during
oral healthcare interventions (Wilson et al
2018). The Code (NMC 2018) states that
nurses need to recognise when people are
distressed or anxious and to respond to
this with compassion. Therefore, knowing
the person, the way they communicate,
their preferences, likes and dislikes and
baseline disposition is essential to ensure

that a person-centred approach to care
is maintained. Assessment tools such as
the Disability Distress Assessment Tool
(DisDAT) (Regnard et al 2007) can be
used to provide an understanding of an
individual’s baseline disposition and to
recognise when they are likely to become
increasingly distressed.

TIME OUT 2
In the context of oral healthcare and access to dental
services, how might an assessment tool, such as the
DisDAT be useful in your practice? Discuss this with
your colleagues, for example, asking them how they
identify when an individual may be in distress

The Code (NMC 2018) states that nurses
must ‘pay special attention to promoting
well-being, preventing ill-health and meeting
the changing health and care needs of people
during all life stages’. Nurses need to be able
to adapt and respond to the needs of people
with intellectual disabilities in different
settings and at various points across their
lifespan (McCarron et al 2018) to provide
person-centred care. McCarron et al (2018)
detailed the various lifespan stages (infancy,
childhood, adolescence, young adult, adult,
middle age, older adult and end of life)
and described a person-centred model that
outlines the different forms of nursing care
and support that an individual may require
at each of these stages.

The need to treat people with respect,
kindness and compassion is also
emphasised in the Code (NMC 2018).
Brown et al (2016) developed a model
of compassionate, person-centred care
in the context of intellectual disability
liaison nursing in the acute hospital
setting. This model is particularly
suitable for supporting the oral health
care needs of people with intellectual
disabilities, for example, ensuring that clear
communication pathways are established
and maintained between the patient,
healthcare providers and family members.

Another person-centred care model that
could be used to support this population
is Moulster et al’s (2019) intellectual

FURTHER RESOURCES
Trinity College Dublin
has developed the Brush
My Teeth website, which
provides several resources
to support people with
intellectual disabilities
and their carers with
oral care, as well as the
following videos:
Trinity College Dublin (2018)
Brush My Teeth
www.brushmyteeth.ie
Normal Brush and No Help
youtu.be/qQj0ajzomZk
Normal Brush and a Little
Help
youtu.be/Gmkqk_hv3FI
Normal Brush and A Lot
of Help
youtu.be/Xbt0yFuN_N4

learningdisabilitypractice.com volume 24 number 2 / April 2021 / 3 7

| PEER-RE VI E WED |evidence & practice / CPD / mouth care

disability nursing practice model. This
model emphasises the benefits for nurses of
reflecting on their care, providing evidence-
based care and promoting care that focuses
on outcomes. Considering the lack of clear
evidence in relation to oral healthcare
for people with intellectual disabilities,
this model can support the development
of evidence-based person-centred oral
healthcare in this population. Waldron et al
(2019) also stated that individualised oral
healthcare plans have been shown to be
effective in meeting the needs of people
with intellectual disabilities.

TIME OUT 3
Consider how Moulster et al (2019) and Brown et al’s
(2016) models could be used to structure a person-
centred approach to oral healthcare in your practice
setting. What changes might you need to make
to your practice to ensure the care provided was
person-centred?

Accessing oral healthcare support
and dental services
It is important for nurses to be able to
identify the challenges that people with
intellectual disabilities experience in
accessing oral healthcare support and
dental services. Nurses should be able
to consider how using evidence-based
guidelines such as PHE’s (2019) guidance
on oral care can improve access to
appropriate dental services for people with
intellectual disabilities.

The Code (NMC 2018) emphasises the
need to work in partnership with the person
to access the healthcare that they need.
It also emphasises the need to advocate
for vulnerable people and to challenge any
discriminatory behaviour and attitudes
relating to their care. The role of intellectual
disability liaison nurse is crucial in ensuring
mainstream healthcare services are
accessible to this population. These nurses
support the person with an intellectual
disability to communicate with others
and educate mainstream healthcare
professionals on how to make services
more accessible (Brown et al 2016).

McCarron et al (2018) stated that
specialisation in intellectual disability
nursing should be influenced by the
changing needs of this population, and
emphasised the importance of evidence-
based practice in this field. Considering
the limited evidence on oral health and
the unmet oral healthcare needs of people
with intellectual disabilities, it could be
suggested that there is a vital role for
intellectual disability liaison nurses who
specialise in access to mainstream dental
care. This role could support people to
address and overcome the challenges they
experience when accessing dental care.

TIME OUT 4
Discuss with a colleague how the development of
the role of an oral healthcare intellectual disability
liaison nurse could ‘bridge the gap’ between the
people with intellectual disabilities and mainstream
dental services. Consider any benefits that access to
a liaison nurse could provide for this population

Mac Giolla Phadraig et al (2015b)
undertook a focus group with six people
with intellectual disabilities to discuss
access to dental services in Ireland. The
study participants expressed feelings of
disempowerment when interacting with
mainstream dental services. Mac Giolla
Phadraig et al (2015b) questioned the
appropriateness of mainstream services for
meeting the oral healthcare needs of people
with intellectual disabilities, but recognised
that their unmet needs represented a complex
issue which cannot be attributed solely to
a lack of resources in mainstream services.

Mac Giolla Phadraig et al (2015b) also
stated that the inclusive focus group method
they employed enabled them to access the
views of people with intellectual disabilities
and could be used in the future to enable the
voices of vulnerable groups to be articulated
and heard. They also recommended that
Irish dental services should ensure equal
access for people with intellectual disabilities
and emphasised the importance of
including the perspectives of service users
when redesigning services.

learningdisabilitypractice.com3 8 / April 2021 / volume 24 number 2

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One significant barrier to effective oral
healthcare is a lack of specific training for
dentists to support this population, which can
limit access (Smith et al 2010). For example,
people with intellectual disabilities having
limited access to dental services may result
in them experiencing long waiting times for
a general anaesthetic when undergoing dental
procedures (Irish Society of Disability and
Oral Health 2012, McGeown et al 2012).

Box 3 provides recommendations
for supporting people with intellectual
disabilities with their oral healthcare.

There is a need for training and education
to improve oral healthcare and dental services
for people with intellectual disabilities.
This training and education are necessary
for family carers, professional carers,
dental professionals and dental surgery
staff, as well as for people with intellectual
disabilities. Box 4 details the training and
education required for carers and dental
professionals to support this population.

TIME OUT 5
Watch the following Well Connected video, which
features people with intellectual disabilities taking
on the role of dental ambassador to encourage
others to access dental services: youtu.be/
WUsENGNs0e8. Do you think that such an initiative
could be useful in your practice setting to support
people with intellectual disabilities to access
mainstream dental services?

Conclusion
Oral healthcare delivered using a person-
centred approach that is adapted to
the person’s preferences and living
circumstances has an essential role in
improving the overall well-being of people
with intellectual disabilities.

At present, the availability of, and
access to, person-centred oral healthcare is
inadequate. Access to services and support
for people with intellectual disabilities
needs to be improved not only at a local
practice setting level, but also at a national
level. Evidence indicates that, in addition
to the lack of access to person-centred
support with oral healthcare, people with

intellectual disabilities do not have equal
access to mainstream dental health services.

Nurses need to support this population
to express their need for improved access
to oral healthcare and dental services.
They also need to be aware of the evidence
concerning the unmet oral healthcare needs
of people with intellectual disabilities, the
oral health risk factors for this population
and interventions associated with improved

Box 3. Recommendations for supporting people with
intellectual disabilities with their oral healthcare

General recommendations
» Supporting the person to have control and choices in their care and treatment can reduce
their anxiety
» People with intellectual disabilities should be viewed as active participants rather than
passive recipients of their dental care
» Appointments need to provide sufficient time for adequate and appropriate explanations of
the dental care and treatment being undertaken
» Easy-read booklets and other information can be provided for people with intellectual
disabilities before the appointment to assist them to prepare
» Cognitive behavioural interventions, for example coping strategies and relaxation
techniques, can assist in reducing a person’s anxiety concerning dental care and may need
to be adapted using a person-centred approach
» It is important to communicate to the person about any delays while waiting for their
appointment
» Where possible, arrangements should be made to avoid the waiting room since this may
cause the person to become anxious

Developing an effective relationship
Factors that can assist people with intellectual disabilities to develop trust in their dentist
include:
» A positive attitude towards people with intellectual disabilities, being respectful and patient
» Adapting communication to accommodate the person
» Knowledge of specific dental issues common in people with intellectual disabilities
» A person-centred approach to oral healthcare and dental services

Reasonable adjustments
In relation to dental care for people with intellectual disabilities, reasonable adjustments may
include:
» Use of the first appointment in the morning
» Longer appointments
» Use of easy-read materials and other resources to support the person to …

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