TOOTHBRUSHING BARRIERS

ARTICLE ABSTRACT Purpose: The aims of this study were: (1) to determine which step in tooth brushing is most difficult for individuals with developmental disabilities and (2) to determine if oral hygiene instruction improves technique. Material and methods: Once per week for 6 weeks, disclosing solution was applied to the teeth of 14 subjects who were observed individually in their tooth brushing technique. Fourteen distinct steps were measured on a 4-point Likert scale. Plaque score was measured after brushing. Results: The step causing greatest difficulty was “able to brush off residual, identified plaque.” Steps that showed greatest improvement were “open toothpaste” and “place toothpaste on brush.” The change in plaque score from the initial visit to the final visit was not statistically significant. Conclusion: Oral hygiene instruction in a group and individual setting increased compliance in the initial steps of tooth brushing.

KEY WORDS:

access/barriers to care, developmentally disabled, oral health

Toothbrushing barriers for people with developmental disabilities: a pilot study Christina J. Shin, DDS;1 Sophia Saeed, DMD2* 1Harvard

School of Dental Medicine, Pediatric Dentistry, Boston, Massachusetts, United States; of California, San Francisco-School of Dentistry, Oral & Maxillofacial Surgery, 521 Parnassus Avenue, Box 0440, San Francisco, California, United States. *Corresponding author e-mail: [email protected] 2University

Spec Care Dentist 33(6): 269-274, 2013

In t r od uct ion Dental care is the number one unmet health care need for individuals with developmental disabilities (DD)1-18 who experience a higher burden of dental disease than the general public.9,19-26 Examples of DD include cerebral palsy, seizure disorder, autism, Down Syndrome, and intellectual disability.27 A number of barriers to accessing health care have been identified, which fall into three main categories: lack of resources,5,20,28-30 lack of organizational support,29 and lack of knowledgeable health care professionals.5,9,12,20,29-32 More specifically, the increased time and resources it takes to care for this population,5,26,28,32,33 the low reimbursement rate from Medicaid,5,9,12,30-33 transportation to/from appointment,5,30-32 liability/legal concerns,30 the complexity of the medical issues which necessitates multiple appointments to multiple providers,4,34,35 high turnover rate of caregivers who generally have a low health literacy,30-32 and unorganized community resources all impede access to health care.

Children from low-income and minority families, and those with special health care needs are at highest risk of oral disease.5,19,20 Those with DD often have additional dental problems including malocclusions, mouth breathing, tongue thrusting, macroglossia, gingival overgrowth, bruxism, and poor oromotor control of saliva.30,32,36,37 Some require specialized dental services, including sedation in an outpatient or hospital setting,32 which is expensive and often have long waiting lists. Patients with DD also have a higher pain tolerance than the general public and sometimes have difficulty expressing pain. By the time dental disease is recognized, it often requires extensive and invasive care. It is well documented that the mechanical removal of plaque, paired with fluoride, is necessary for preventing dental caries and periodontal dis-

©2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12024

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ease.12,20,30,38,39 Given the difficulty in accessing care and the expense in obtaining specialized services, prevention of dental disease is imperative for individuals with DD.40 With advances in medicine, many children with DD live a longer life span.5,30,36,41 Many pediatric dentists are trained to provide dental care to children with special needs, including DD. As patients outgrow the pediatric clinics, it becomes difficult to find dentists who treat adolescents and adults with DD. This is largely due to the lack of dentists trained to provide care to this adult population. Children and young adults who are given the knowledge and skills to provide preventive self-care in their transitional years may benefit from well-developed health habits throughout life.5,20,42 The purpose of this pilot prospective cohort study was to determine which

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step(s) in the toothbrushing technique pose the greatest challenge for children, adolescents, and young adults with DD. The second aim was to see if repeated oral hygiene instructions decrease the level of plaque over time, when measured after brushing.

Metho ds Study population This study was done in San Francisco, CA, at a recreational day program (RDP) for children and teens with DD. Criteria to be enrolled at the RDP include qualification for Individualized Education Program mandated by the Individuals with Disabilities Education Act for people who are considered disabled by federal regulations. All students in the RDP are between the ages of 6 and 24. Individuals enrolled at RDP have varying degrees of intellectual disability ranging from mild to profound. Their degree of manual dexterity varies from full function to quadriplegic. All 52 individuals enrolled in the RDP were invited to participate in the study. Consent and assent was obtained for 20 individuals aged 6–21 years old. Exclusion criteria included: 1. Subjects for whom we are unable to obtain informed consent or assent. 2. Subjects who could not have plaque disclosing solution applied due to inability to cooperate with investigators. 3. Subjects who could not hold the toothbrush due to physical limitations. 4. Subjects who missed four or more sessions of data collection. A total of 14 subjects were included in the study. Individuals who did not participate in the study received the same oral hygiene instruction at each visit, but no data were recorded.

Intervention Five dentists and one third-year dental student were calibrated to provide a group classroom lesson on oral hygiene, as well as personalized oral hygiene instruction. The group classroom lesson included visual aids for demonstrating plaque removal. Oral hygiene instruction

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was then performed for each student one-by-one at the classroom sink and took approximately 10 minutes per student. Investigators applied plaque disclosing solution (Young Dental Manufacturing, Earth City, MO, USA) on the subject’s teeth with cotton-tip applicators. Investigators laid out the student’s Sonicare® (Philips Oral Healthcare, Snoqualmie, WA, USA) electric toothbrush and individual Colgate Total® (Colgate-Palmolive Company, Piscataway, NJ, USA) toothpaste tube next to the sink and students were asked to open the toothpaste tube, apply paste to the brush, adapt the brush to their teeth, and brush to remove the disclosing solution. Students stood in front of a mirror during this exercise. Each student was allowed to brush for as long or short as s/he felt was needed for thorough brushing to remove identified plaque. Personal protective equipment was worn for each interaction and infection control standards were followed. Individual toothbrushes and toothpaste tubes were labeled for each student and stored between visits in compliance with infection control standards.

Oral examinations One investigator (CS) recorded observed barriers to toothbrushing using a modified version of the Oral Hygiene Skill Survey developed by the Center for Oral Health for People with Special Needs (now called Pacific Center for Special Care, Arthur A. Dugoni School of Dentistry, San Francisco, CA, USA) which identifies 14 chronological and distinct steps in the toothbrushing technique (Appendix A). A 4-point Likert-type scale of 0 to 3 allowed the investigator to quantify how much of a barrier each step posed (0 = inability to complete step, 1 = dentist completes step for individual, 2 = need to prompt for individual to complete step, 3 = individual completes step independently). A separate investigator (SF) recorded plaque score after each subject attempted to individually remove disclosed plaque. A modified version of the Simplified Oral Hygiene Index (OHI-S) defined by

Greene and Vermillion43 was used, with a 4-point Likert-type scale of 0 = “no plaque present” to 3 = “tooth surface covered mostly in plaque.” Plaque level was recorded on 6 different tooth surfaces: #3 buccal, 8 buccal, 14 buccal, 19 lingual, 24 buccal, 30 lingual for each subject. Calculus was not measured. If disclosing solution remained on the teeth after the 14 brushing steps, investigators guided subjects to brush off residing plaque. If they were unable to remove remaining plaque independently, investigators assisted. No additional measurements were taken. This process was completed with all students in attendance at the JPC CTD each Wednesday afternoon for 6 consecutive weeks in the Spring of 2011; data were only recorded for the 14 study subjects. At the final session, each student received his/her electric toothbrush to take home, along with a packet of contact information for local dentists who accept patients with DD.

Ethical approval This study protocol was approved by Committee on Human Research at University of California, San Francisco (Study number: 10-04837).

Data analysis Barrier scores for each subject were compared for each step from the initial visit to the final visit. Additionally, the average barrier score for all 14 study subjects was calculated for each of the six visits and for the total of all visits. Plaque scores for each subject were compared for each tooth surface at each visit for individuals and for the overall group. The change in barrier score was related to the change in plaque score. Microsoft Excel (Redmond, WA, USA) was used to take the average and the standard deviation of scores.

R es ul t s The steps “able to brush off residing, identified plaque” and “brush inside and outside of front teeth” had the lowest

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Table 1. Barrier scores for 14 steps of tooth brushing technique. Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Average

Final – Initial

1. Identify own brush

2.60

2.80

2.90

3.00

3.00

3.00

2.88

0.40

2. Approach sink

3.00

2.90

2.75

3.00

3.00

3.00

2.94

0.00

3. Pick up brush

2.60

2.80

2.75

3.00

3.00

3.00

2.86

0.40

4. Open toothpaste

2.00

2.20

2.60

2.80

2.40

2.80

2.47

0.80

5. Place toothpaste on brush

2.10

2.50

2.70

3.00

2.40

2.80

2.58

0.70

6. Keep brush in mouth for 5 seconds

3.00

2.80

2.80

3.00

2.80

2.80

2.87

−0.20

7. Keep brush in mouth for 1 minute

2.70

2.70

2.80

3.00

2.80

2.80

2.80

0.10

8. Keep brush in mouth for 2 minutes

2.40

2.50

2.70

2.70

2.50

2.60

2.57

0.20

9. Brush inside and outside front teeth

2.30

2.10

1.80

1.70

2.20

2.30

2.07

0.00

10. Brush back teeth

2.60

2.50

2.30

2.40

2.40

2.50

2.45

−0.10

11. Brush chewing surfaces of teeth

2.80

2.60

2.60

2.80

2.80

2.70

2.72

−0.10

12. Rinse and spit

3.00

2.80

2.80

3.00

2.80

3.00

2.90

0.00

13. Able to identify plaque residue with mirror

2.60

2.40

2.60

2.30

2.20

2.40

2.42

−0.20

14. Able to brush off residing, identified plaque

1.40

1.60

1.60

1.70

1.80

2.10

1.70

0.70

Average

2.51

2.51

2.55

2.67

2.58

2.70

Table 2. Initial and final plaque scores for 6 tooth surfaces. Tooth surface

Week 1

Week 6

Variance

#3B

0.55

0.78

0.23

#8B

0.91

0.56

−0.35

#14B

0.82

0.00

−0.82

#30L

0.82

0.89

0.07

#24B

0.91

0.89

−0.02

#19L

0.82

0.56

−0.26

Average

0.81

0.61

−0.19

Table 3. Weekly average of plaque score for all tooth surfaces. Week

1

2

3

4

5

6

Average plaque score

0.81

0.58

0.70

0.47

0.43

0.61

Standard deviation

0.88

0.68

0.71

0.64

0.79

0.70

average score for all subjects over the 6 weeks (1.70 SD +/−0.99 and 2.07 SD+/−0.76, respectively). Other steps had minimal variability in average scores, ranging from 2.42 to 2.94 (Table 1). Subjects were best able to “approach sink” (2.94 SD+/−0.53). Though not statically significant, the overall average score for all subjects for all steps at the initial visit was 2.51, with an improvement to 2.70 at the final visit. This

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change was not linear, as week 5 showed a decrease in average scores. The step with the greatest improvement was “open toothpaste” with an overall increase of 0.80 on the 4-point scale. The steps “open toothpaste,” “place toothpaste on brush,” and “able to brush of residing, identified plaque” also showed improvement (0.80, 0.70, and 0.70, respectively). Three steps showed deterioration from the initial to the final visit: “keep brush

in mouth for 5 seconds” (−0.20), “brush chewing surfaces of teeth” (−0.10), and “able to identify plaque residue with mirror” (−0.20). The tooth surfaces with the greatest amount of plaque at the initial visit were #8 buccal (0.91) and #24 buccal (0.91) and the surface with the least amount of plaque at the initial visit was #3 buccal (Table 2). At the final visit, #14 buccal had the least amount of plaque (0.00), while #30 lingual (0.89) and #24 buccal (0.89) had the most amount of plaque. The greatest improvement from initial to final visit was seen in #14 buccal (−0.82), while deterioration was seen for #3 buccal (0.23). The average score for all surfaces combined ranged from 0.43 (week 5) to 0.70 (week 3) (Table 3) with a final change of −0.19 from initial to final visits. Individual subjects were then divided into those who showed decreased plaque level, no change, or increased plaque level and plotted against changes in barriers to steps in toothbrushing. Eight subjects showed an improvement in both toothbrushing technique and plaque removal, while two subjects actually showed a decline in both technique and plaque score from our intervention (Table 4).

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Table 4. Subjects’ plaque level compared to barriers in tooth brushing technique. Decreased plaque level

No change

Increased plaque level

Decreased barrier

8

1

1

No change

0

0

0

Increased barrier

1

1

2

D is cu ssi o n Steps in the toothbrushing technique that posed the greatest challenge for subjects—“able to brush off residing, identified plaque” and “brush inside and outside of front teeth”—require a higher degree of manual dexterity, comprehension, and coordination than other steps. Similarly, the steps that were easiest for the subjects—“approach sink,” “rinse and spit,” “identify own brush,” and “pick up brush” are simpler tasks that require less coordination. Tasks that required a moderate amount of coordination—“open toothpaste,” “place toothpaste on brush” and “able to brush of residing, identified plaque”—showed the greatest improvement, however it was not statistically significant. The use of disclosing solution appears to have made a difference in subjects’ ability to identify plaque. The step “open toothpaste” was the second most difficult step in the toothbrushing technique at the first visit. Toothpaste tubes used in this study had a screw-on design. Designs with larger caps or flip-top caps may be easier to use for individuals with limited dexterity. In regards to the plaque score, much of the oral hygiene instruction focused on wrist rotation to access both the right and left sides of the mouth. While this improved the hygiene on #14 buccal, there was a deterioration in the oral hygiene on the left side of the mouth (#3 buccal). The buccal surface of #24, though easily accessible, remained difficult for subjects to clean adequately. This may be because of the coordination it requires to relax the lower lip in order to place the toothbrush into the vestibule and access that surface. It is anecdotally reported that individuals with DD have a strong lower lip.

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Eight individuals who showed an improvement in toothbrushing technique also demonstrated improved oral hygiene. Given the variability of cognitive and physical abilities of the subjects, it would have been beneficial to have a physician provide standardized diagnoses to relate to the subjects’ abilities. Interestingly, there was a regression in toothbrushing technique at week 5 (2.58), yet the average plaque scores that week were the most favorable (0.43). Concurrent with our study on that day was an end-of-the-year school barbeque which may have caused distraction from tooth brushing technique. Students were also snacking throughout the afternoon, and their encounters with the investigators may have been before or after food consumption. On all other visits (week 1–4 and week 6), snack time occurred at a consistent time after the toothbrushing and plaque scores were measured. The study’s limitations must be considered when interpreting results of this pilot study. The sample population is small and may not be representative of children and adolescents with DD. First, informed consent for this vulnerable population was challenging because of the vast range of age, intellectual ability, family involvement, and availability of legal surrogate. Some individuals were cognitively slower than average, yet could understand and communicate if given time. Others were nonverbal and would not stay still for longer than a few seconds. Confirming their consent and assent was challenging, therefore the sample size was very small. The issue of informed consent has been previously reported in regards to provision of health care; the different regulations regarding human research complicate the matter even more.

Next, most individuals enrolled at the community center are better connected with resources and infrastructure than individuals who are not enrolled. Also, only individuals with enough dexterity to hold a toothbrush were included. Third, collecting demographic data may have been helpful in data analysis. Age, gender, right- versus left-handed, and standardized medical diagnosis of cognitive and physical abilities could affect the plaque scores. Fourth, we did not record calculus score for the OHI-S. All measurements were visual approximations and no sharp instruments were used. This was done for the safety of the subjects and investigators, as some individuals in our study had involuntary movements. Fifth, coordinating with the community center’s schedule was challenging. The structure of their days is different than what we expected. Weather, special guests, birthdays, and teacher and student absences all impacted a standardized environment. Because the individual OHI was conducted in a corner of the classroom where others could see, there may have been a degree of social desirability that impacted our measurements. Next, it would have been helpful to get background information on the amount of help each subject gets with oral care at home to determine if including the caregiver in our study would improve outcomes. Further, knowing if the subject had prior experience with an electric toothbrush may impact the measurements. During the study, some subjects chose not to turn the electric brush on and used it strictly as a manual toothbrush with a large handle. In future studies that use electric brushes, it would be prudent to record this preference. Finally, the study was limited to 6 weeks due to summer break at the community center and investigator availability. While this short amount of time did not demonstrate effectiveness in tooth brushing technique or plaque reduction, it could be postulated that a longer or more frequent intervention may have had different results. Learning new tasks that require coordination may be particularly difficult for this population.

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Conclusions Prevention of dental diseases is key for all individuals, but even more important for those who have difficulty accessing and obtaining health care. Children and young adults with DD have a higher burden of dental disease than the general population, and dental care remains the greatest unmet health care need. While limited in sample size, this study suggests that traditional oral hygiene instruction may not be effective for young people with DD. Further research is needed to determine effective preventive protocols—a combination of home care and professional care—for the wide range of individuals with DD.

5.

6.

7.

8.

Acknowledgements The authors would like to thank Todor Stavrev for his assistance with statistical analysis.

S ou r ce of fundi ng Electric toothbrushes were donated by Phillips Sonicare (Philips Oral Healthcare, Snoqualmie, WA, USA) and Colgate Total toothpaste was donated by Colgate Oral Pharmaceuticals (Colgate-Palmolive Company, Piscataway, NJ, USA).

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Appen di x A O r al hygi e ne ski ll sur vey ( s a m p l e) Name John___________

Caregiver Name Bill____________

Client Behavior STEPS

Dates

Start Date 10/29/03________ Comments and Behavior

10/29

11/9

11/23

1 Identify own brush

3

3

3

2 Approach sink

2

2

2

Need to point at brush and then sink to get him to wet it

3 Pick up wet brush

2

2

2

Have to tell him to put on toothpaste.

4 Put toothpaste on brush

2

2

2

Say “how put the toothbrush in your mouth”

5 Put toothbrush in mouth

1

2

2

Needs constant verbal praise

6 Keep brush in mouth for 5 seconds

1

2

2

Needs constant gentle touch of hand or verbal praise

7 Keep brush in mouth for 1 minute

1

1

2

Lie on couch for me to hold his mouth open

8 Keep brush in mouth for 2 minute

1

1

2

Lie on couch for me to hole his mouth open

9 Brush inside/outside front teeth

1

1

1

Could not brush chewing surface on back side of right side

10 Brush inside outside back teeth

0

1

1

Will rinse if told to do so Needed to point to brush holder at first

11 Brush chewing surfaces of teeth

1

2

2

12 Rinse and spit

2

3

3

13 Put toothbrush/toothpaste away

3

3

3

0123-

Inability to complete step Dentist completes step for individual Need to prompt for individual to complete step Individual completes step independently

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