Learning Disabilities and Oral Health

As a Special Care Dentist, I spent a lot of my time managing and looking after people who have Learning Disabilities... so what adaptations do I have to make?

What is Learning Disability?

A learning disability (LD) is a reduced intellectual ability and difficulty with everyday activities such as household tasks, socialising or managing money. This affects someone for their whole life. According to the charity MenCap, people with a learning disability tend to take longer to learn and may need support to develop new skills, understand complicated information and interact with other people. 

There are different types of learning disability, which can be mild, moderate, severe or profound. In all cases a learning disability is lifelong. People who are at the more profound end of the spectrum will need more care and support in areas such as mobility, personal care and communication. 

A learning disability occurs when the brain is still developing which can be before, during or soon after birth. There are several causes of a learning disability, such as if the mother has an accident while she is pregnant, or from genetic mutations, or from deprivation of oxygen during childbirth, or premature birth.

You are described as disabled under the Equality Act 2010 if you have a mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on your ability to do normal daily activities.

Approximately 1. 5 million people in the UK have a learning disability.

What about the Oral Health of People with Learning Disability?

There has been evidence to show people with disabilities have a poorer standard of oral health, with:

  • Higher levels of periodontal disease
  • Greater gingival inflammation
  • Higher numbers of missing teeth
  • Increased rates of edentulism
  • Higher plaque levels
  • Greater unmet oral health needs
  • Poorer access to dental services and less preventative dentistry

Access to generic high street services can be challenging as they are often designed without the input of a person living with disabilities. While more specialist services exist to cater for disabled people such as community or hospital dental services, there can still be barriers which prevent access for these groups such as: 

1. Accessibility

  • People with learning disabilities may find getting to a clinic difficult in the first place. Services may not be close to public transport links or be centrally located so patients do not have to travel great distances or have parking facilities for patients who need to travel by car. 
  • Patient pathways may not be clear, with difficulty getting into a service or being able to self-refer themselves to services. 
  • Many patients with learning disabilities also have physical disabilities and are confined to wheelchairs. This could mean ensuring there are accessibility barriers for patients who are wheelchair users with services lacking ramps, ground floor surgeries or lifts, or specialist equipment such as hoists or wheelchair tippers. Not only the dental surgery itself, but the building it is in may have barriers, such as lack of adaptations including wide doors, bariatric waiting chairs and toilets and disabled toilets such as a Changing Places toilet. 
  • The environment may not be designed so it is calming for patients with mental or social disabilities such as autism; calm music being played, toys or paintings for example can help.
  • A disability-friendly service should be available for people to access at an accepted distance to travel for these patients. There should not be a postcode lottery as to what facilities services are commissioned to do. Commissioners should follow the Special Care Commissioning guidance in order to provide an equitable standard of care across regions.

2. Affordability

  • We know that patients with learning disabilities are more likely to live in poverty. The cost of dentistry itself might not be affordable for these patients. 
  • If they are NHS patients, it may not be clear and easy to find out whether the patient is exempt from dental charges
  • Appointments might not be at convenient times for carers/relatives to bring patients to, or the clinic be too far away for patients who may struggle to afford to pay for travel to the clinic. 

3. Consent, Cooperation & Communication

  • Many patients with learning disabilities may not have capacity to consent, although it should always be assumed that the patient has capacity. The principles of the Mental Capacity Act should be followed to make reasonable adjustments to help patients understand the consent process if possible, or if not, clinicians act in their best interests. 
  • Independent Mental Capacity Advocates may need to be consulted where decision making is unclear. 
  • Patients with learning disabilities may have difficulty in communicating. This may be as profound as being unable to communicate if they are experiencing dental pain, but also whether they understand instructions given by clinicians or to express decisions. 
  • Aids such as easy-read, pictures or Makaton may be useful aids for communication, 
  • Many patients are anxious, uncooperative or have compounding factors such as hypersensitive gag reflexes or tremors and therefore would require sedation or general anaesthetic to be able to manage treatment. 
  • Not all dental services provide these; with a lack of appropriate facilities, such as theatre space, as well as appropriate staff training and skill mix or staff who are used to working with these patient’s needs.

4. Education & Social History

  • People with learning disabilities may not be aware of the importance of oral health, or how to access a dentist when they need it. This may result in an increased burden of dental disease, or patients not accessing services regularly. 
  • People who care for patients with learning disabilities may not value oral health above the other health and social care needs of their patients. If these patients are housed together, managing the needs of multiple people with social care staff who may be understaffed or under-motivated could result in lack of oral care, or delayed presentation to dental services. 

5. Co-Morbidities

  • Some patients with learning disabilities have other co-morbidities that affect their oral health. 
  • For example patients with Down Syndrome while have learning disabilities, are more prone to periodontal disease and other tooth anomalies. 
  • Patients with Autism Spectrum Disorder could suffer from trauma following an epileptic seizure or with stimming habits that affect their oral health. 

To find out more, check out this great guidance document by Public Health England about Dentistry and Learning Disabilities.

Do you have any questions about learning disabilities and dentistry? Please leave them in the comments below

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