Oral disease affects overall health, nutrition and wellbeing. Poor oral health can lead to pain, difficulty eating, sleep disturbance, and decreased self-esteem, all of which can impact adversely on quality of life. These impacts are more common among people with intellectual and physical disabilities (or ‘special needs’) than the general population. This inequality is compounded by their poor access to health care. While public dental care is available to concession card holders for a capped co-payment, resource constraints mean there are significant waiting times for treatment, and less emphasis on preventive care. Consequently, patients with special needs often require emergency treatment for oral disease and this involves hospital admissions and general anaesthesia. Oral health knowledge among this group and their carers, where they require them, is also relatively poor.
Australia’s National Oral Health Plan 2004–2013 identified ‘people with special needs’ as a priority in ‘Action Area Five’, defining them broadly as ‘people with physical and intellectual disability, or medical or psychiatric conditions that increase their risk of oral health problems or increase the complexity of oral health care’. However, this group remains the only one identified in the Plan for which there is no Australian population data. This is probably due both to the heterogeneity of the group and difficulties with access to individuals, and their consent to research.
Ability to self-care varies widely for these people. Some depend on carers, either family or professionals, for help with everyday activities. Deinstitutionalisation of people with disabilities in Australia has meant that commonly four to five people with similar needs now live together in the community in group homes under 24-hour carer support. Carers are therefore often ideally placed to detect problems and facilitate access to services. They are also responsible for providing daily personal care, healthy nutrition and regular visits to health services, including oral hygiene care and dental visits. Those people with limited or no communication skills and unable to express pain and discomfort require additional input and vigilance from carers. A South Australian study found that carers were unable to report oral health-related quality of life (OHRQoL) for many care recipients with limited communication. Training of carers in oral care is therefore strongly recommended in the literature.
Some studies have suggested that training in oral care should address the oral care behaviours of carers and psychosocial factors, and two measures have been developed to evaluate the behaviours of carers. One refers to self-efficacy in oral care behaviours. Self-efficacy is a construct of Social Cognitive Theory that refers to an individual's perceived ability to perform a specified behaviour/s, determining what individuals do with the knowledge and skills they have acquired. Another refers to carers’ knowledge, confidence and skills in providing oral health care for their care recipients. The psychometric properties of the measures are detailed elsewhere.
Although there are few studies evaluating oral care training for carers of people with disabilities, most have demonstrated positive outcomes. Outcomes in one study include improved knowledge among carers and in another improved carer attitudes, behaviours and hygiene of care recipients. A ‘train-the-trainer’ approach was used by an Irish study, which improved carer self-efficacy as well as attitudes and behaviours, although a study from the US failed to identify an impact on self-efficacy. In Australia, training in oral care has been limited mostly to aged care settings. In a South Australian study, significant improvement in the oral health status of residents resulted from the training of general practitioners (GPs) and registered nurses (RNs) in aged care facilities.
Other people with special needs who live independently have the capacity to self-care and may work in assisted employment. They can self-consent to research and self-report on their health status. Nonetheless, the oral health of these people where measured remains relatively poor. One US study surveyed 433 adults enrolled in the Kansas Working Healthy project. Compared with the national population, they had greater prevalence of painful aching, uncomfortable eating, and difficulty working due to dental problems. Dental treatment and direct oral health education may offer benefits to this group. A study in the UK found that the contribution of dental care was greatest in self-image and social interaction. Workplace-based oral health education and/or referral has been shown to benefit oral health and reduce health expenditure in the general working population. A group of 382 adult trainees in the UK with special needs had their oral hygiene and periodontal condition improved by an intervention of regular educational input from a dental hygienist. As well as clinical and quality of life impacts, poor oral health is likely to inhibit work incentive projects aimed at increasing the independence of people with special needs. T our knowledge, there remains no published data in Australia on oral health-related interventions for employees with disabilities.
This study aimed to benefit the oral health and OHRQoL of two groups of people with special needs: ‘care recipients’ (directly and via their carers) and ‘employees’. The study aims reflect the different approaches used.
For carers and care recipients,
- To provide a home-based intervention, training carers in providing improved oral care for adults with disabilities
- To evaluate the intervention by,
- Assessing the change in carer psychosocial factors pre- to post-training
- Benchmarking to a dentist the oral health assessment of carers post-training
- To provide a workplace intervention combining oral health education and timely referral for treatment
- To evaluate the intervention by assessing change in self-rated oral health, OHRQoL and oral health behaviours pre- and post-intervention