Oral hygiene: supporting people with ID and their carers

intellectual disability

Catherine Waldron PhD, who is interviewed on page 170 of this edition, outlines her research into oral health interventions for people with intellectual disability.

When providing dental care for a person with an intellectual disability (ID), it is important to consider the specific needs of the person and the evidence base for the advice we might provide. The oral health of people with ID is poorer than that of the general population. One of the most basic things we can focus on is ensuring that a person’s oral hygiene is the best it can be. This can prevent the need for more invasive, expensive and time-consuming dental treatment in the future.
Toothbrushing is a skill. It needs to be done regularly and may require special tools. It can be difficult for some people to brush well enough to prevent gum disease and tooth decay.

Looking at the evidence
The PhD scholarship I was awarded provided me with the opportunity to make sure that we had the best quality evidence available to us in relation to oral hygiene interventions for people with ID. I undertook a Cochrane review, internationally recognised as the benchmark for high-quality information about the effectiveness of healthcare interventions. However, I was also aware that a Cochrane review might not provide the full picture; many people with ID require help with their toothbrushing and so the behaviour and attitudes of the people who support them, the carers, might also be a factor. It was for this reason that I also undertook a realist review of carer-led oral hygiene interventions for people with ID.

The role of the carer in supporting, assisting or carrying out the toothbrushing was a crucial element.
The Cochrane review was the first Cochrane oral health review to focus on a population with ID. The main interventions identified in the review compared a conventional manual toothbrush to using a special manual toothbrush and to an electric toothbrush, or compared the provision of oral hygiene training to carers and to people with ID, to providing no training.
The behavioural change elements in the interventions were mapped using the COM-B framework (capability, opportunity and motivation) for understanding behaviour and behaviour change. The most common elements identified focused on improving capabilities using training, modelling or enablement in the skill of toothbrushing, and on opportunities such as setting specific times for toothbrushing, providing different oral hygiene aids, or changing the setting where the toothbrushing took place. Motivation was rarely used.

Briefly, the review found that the ‘Superbrush’ may have a greater effect on oral hygiene, but the benefits of using an electric toothbrush compared to a manual toothbrush were inconclusive. The role of the carer in supporting, assisting or carrying out the toothbrushing was a crucial element.
Training carers may increase their oral hygiene knowledge, behaviour, attitudes and self-efficacy, and reduce levels of gingival inflammation among the people they care for. Additionally, the review found that people with ID can acquire the skills to undertake some or all of the steps involved in toothbrushing and this may reduce their plaque levels. However, generally the quality of the data in the studies was poor, and the clinical relevance of the findings unclear.

Realist review
The purpose of the realist review was to consider how, why, when and for whom oral hygiene interventions work, rather than if they work. It was undertaken to identify the contexts and mechanisms that influence the outcomes, implementation and sustainability of carer-led oral hygiene interventions for people with ID, and found the following:

  • the content and delivery of oral care training for carers, such as setting goals with achievable steps, and support from the organisation, with regular feedback to carers in relation to the impact of their input, all play important roles in the success of interventions;
  • devoting time to the planning and design stages of interventions, involving the stakeholders and providing clear statements of how the initiative is expected to work and the behaviour change techniques being used, is important; and,
  • the need for resources to ensure sustainability, in the form of staff and training, and for evaluation of the intervention, must be built into the budget.The physical and emotional toll on carers when providing consistent care to people with ID, who may often not understand the need for the care and resist it, was startling in this review. We need to show understanding and empathy, and provide support to the carers we meet when providing dental care to the people they care for.

Although the findings predominantly relate to group interventions, many of the elements can be applied to individual interactions with people with ID and their carers in practice:

  • set achievable goals;
  • provide support and praise; and,
  • refresh the health messages regularly.

Please find more details in the two reviews: