1 7 4 - D e n t a l P r a c t i c e J a n u a r y / F e b r u a r y 2 0 0 5

S pecial Needs Dentistry is concernedwith the oral health management ofmedically compromised patients

and of people with disabilities. Thisincludes the frail elderly, people withmental illness and intellectual disability.As oral health professionals, we are compelled to understand the needs of thedisabled, identify dental implications andcustomise treatment plans to address theirneeds. In this article, I would like to identify two problems that I see regularlyin the special needs population that can have a devastating effect if not managed properly.

1. Rampent root caries in dentate patients with dementiaOver the past 25 years, there has been afive-fold increase in the number of peoplewho live past the age of 85. Almost 50% ofpeople over 85 will develop dementia andmany will be frail and disabled in otherways. In the past, most older adults wereedentulous, however, more people are nowretaining their natural dentitions. Further-more, older adults are presenting withcomplex restorations including crowns,bridges and implants. All dental profes-sionals will be exposed to the complexityof maintaining good oral health in this veryspecial population, the frail eldery.

Why can a patient with dementiadevelop rampant root caries?• Poor plaque removal due to lack of dexterity;• Reliance on carers who may not havegood oral health behaviours or find it diffi-cult to deliver oral care;• Dietary changes, which include morefrequent ingestion of smaller meals thatare high in carbohydrates;• Poor oral clearance of foodstuff leavingfood debris in the labial sulcus;• Drug induced xerostomia; and/or• Inadequate use of preventive products(Fluoride, Chlorhexidine, Phenolic com-pounds, CPP ACP).

Caries can reach rampant proportions ina short space of time and healthy dentitionscan be destroyed by root caries in a matterof months. In addition to dietary coun-seling and consideration to xerostomia, the

dentate patient developing dementia needsto be placed on a preventive regime thatwill stop root caries developing.

The preventive regime needs to cater tothe patient’s abilities and caries risk. Somepatients will be prescribed small mealsregularly by their dietician to maintainweight. These patients require fluoridedelivery more often that twice daily.Chemical and professional regimes toprevent caries can include:• The use of Fuji V11 to seal susceptibleroot surfaces;• Professional application of fluoridewith attention to root surfaces every threemonths in high risk patients;• Construction of fluoride trays for homeuse on a weekly basis with a fluoride gel;• The use of a high fluoride level toothpaste;• The use of fluoride tablets. If the patientfails to clear food from their mouth, theyare also likely to leave a fluoride tablet todissolve in their sulcus without swal-lowing it. If the patient is in a nursinghome, it can be included on their medica-tion chart to ensure that the patient isgiven the tablet after each meal;• The use of an atomizer. If the patientcannot rinse, use an atomiser to spraymouthrinse into the mouth. These atom-isers can be used with chlorhexidinemouthrinse, phenolic compounds or fluo-ride mouthrinse. Carers are often happy tocomply with the use of atomizers todeliver mouth rinses and the efficacy ofspraying compared to rinsing is favorable.The use of atomizers can also be added tothe patients medication chart in nursinghomes to ensure that the product is deliv-ered regularly; and/or• CPP-ACP in tooth mousse may beacceptable to the patient and carers.

Without a high level of prevention andadaptations to suit both the patient and thecaregiver, many patients with dementiawill develop rampant caries and conserva-tive treatment will require a generalanaesthetic. In addition to the use ofchemical and professional regimes to pre-vent caries, oral hygiene competence incarers need to be addressed since there is astrong correlation between plaque levelsand the incidence of root caries.

2. Management of tooth wear in patients with intellectual disabilityIn young adults with intellectual disability,tooth wear is often overlooked and cancause considerable distress and ultimatelytooth loss. There is an increased incidenceof tooth wear in patient with disabilitiesdue to a higher prevalence of gastrooe-sophageal reflux disorder (GORD).However, these patients are unlikely tocommunicate the symptoms of GORD.Dental erosion may be the first evidence ofGORD that a health professional can iden-tify in a patient with intellectual disability.If a patient with an intellectual disabilitypresents with tooth wear, the level of toothwear should be recorded using studymodels or photographs so that tooth tissueloss can be monitored over time. If a patientis losing tooth tissue, the cause needs to beidentified. Referral to a gastroenterologistis indicated if non-occluding surfaces areheavily worn. The gastroenterologist caninvestigate the possibility of reflux disorderand provide the appropriate management.

Grinding is also more common inpatients with intellectual disability. How-ever, it is often in combination with GORDthat rapid loss of tooth tissue occurs inpatients with intellectual disability.

SummaryTwo devastating processes in specialneeds populations are rampant root cariesin the demented elderly and dental erosionfrom GORD in patients with intellectualdisabilities. The oral health professional isin a unique position to effect the quality ofthe life of these patients by appropriateprevention and early diagnosis of theseproblems. These patients will suffer insilence without appropriate care.

Dr Peter King is a visiting staff specialist inSpecial Needs Dentistry in the Hunter AreaHealth Service and also at the WestmeadCentre for Oral Health. He conducts arestricted private practice in Special NeedsDentistry. He is also on the board of studiesfor the RACDS fellowship in Special NeedsDentistry and is a mentor in Special NeedsDentistry in an Australasian project spon-sored by Colgate and Alzheimers Australia.

Special needs, special approachesBY PETER KING, BDS, MDS, FICD

CLINICAL

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