*Karolina Gerreth1, Dorota Olczak-Kowalczyk2, Maria Borysewicz-Lewicka3
Opinion of the Polish Paediatric Dentistry Association (PTSD), Section of Paediatric Dentistry of the Polish Dental Association, Polish Branch of Alliance for a Cavity-Free Future (ACFF) and the National Consultant in Paediatric Dentistry concerning preventive dental recommendations for patients with disabilities
Stanowisko Polskiego Towarzystwa Stomatologii Dziecięcej (PTSD), Sekcji Stomatologii Dziecięcej Polskiego Towarzystwa Stomatologicznego (PTS), Polskiego Oddziału Sojuszu dla Przyszłości Wolnej od Próchnicy (ACFF) i konsultanta krajowego w dziedzinie stomatologii dziecięcej dotyczące stomatologicznych zaleceń profilaktycznych dla pacjentów niepełnosprawnych
1Head of Laboratory of Social Dentistry, Department of Paediatric Dentistry, Poznań University of Medical Sciences, PTSD, PTS, ACFF
2Head of Paediatric Dentistry Department, Medical University of Warsaw, National Consultant in the field of Paediatric Dentistry, Vice-President of PTSD, Coordinator of the Polish branch of ACFF, PTS
3Head of Department of Paediatric Dentistry, Poznań University of Medical Sciences, PTSD, PTS, ACFF
Experts presenting the opinion:
Professor Urszula Kaczmarek, DDS, PhD – Department of Conservative and Paediatric Dentistry, Medical University of Wrocław,
Chairperson of the Central and Eastern Europe Branch of ACFF, PTSD, PTS
Professor Zbigniew Woźniak, MA, PhD – Department of Social Affairs and Social Work, Institute of Sociology,
Adam Mickiewicz University in Poznań
Aleksandra Szczawińska-Popłonyk, MD, PhD – Department of Paediatric Pulmonology, Allergy and Clinical Immunology, Poznań University of Medical Sciences
Anna Jurczak, DDS, PhD – Head of the Department of Paediatric Dentistry, Institute of Dentistry, Collegium Medicum, a chairperson of the Polish Paediatric Dentistry Association, a Board Member of the Section of Paediatric Dentistry of PTS, ACFF
Problem leczenia pacjentów ze specjalnymi potrzebami zdrowotnymi wynikającymi z obecności deficytów w funkcji intelektualnej, ruchowej czy sensorycznej również w stomatologii nie został opracowany kompleksowo. Z danych Światowej Organizacji Zdrowia (WHO) wynika, iż około 15% populacji światowej posiada jakąś formę niepełnosprawności. Pacjenci z obniżoną sprawnością uważani są za populację charakteryzującą się większymi stomatologicznymi potrzebami leczniczymi w porównaniu do grupy osób zdrowych.
Spostrzega się często w tym środowisku wyższą frekwencję oraz intensywność próchnicy zębów i chorób dziąseł. Niejednokrotnie sytuacja związana jest m.in. z występowaniem chorób ogólnoustrojowych oraz stosowanym leczeniem, obecnością ograniczeń w zakresie możliwości wykształcenia prawidłowych stomatologicznych zachowań zdrowotnych, niewystarczającą wiedzą rodziców dotyczącą zdrowia jamy ustnej czy obecnością barier w dostępie do opieki stomatologicznej.
Poprawa sytuacji zdrowotnej tych pacjentów wymaga opracowania wskazówek dla rodziców/opiekunów i personelu medycznego celem poprawy stanu zdrowia i tym samym jakości ich życia. Dokument zawiera informacje dotyczące etiologii i epidemiologii choroby próchnicowej zębów u pacjentów z niepełnosprawnością, ale także zalecenia profilaktyczne dla osób z tej populacji oraz ich rodziców/opiekunów i lekarzy dentystów.
The problem of treatment of patients with special health needs resulting from the presence of deficits in intellectual, motor or sensory functions, also in dentistry, has not been comprehensively solved. According to the World Health Organization (WHO), about 15% of the world population has some form of disability. Patients with disabilities are considered to have greater dental treatment needs in comparison to healthy individuals.
High incidence and intensity of dental caries as well as frequent gum diseases are observed in this environment. Often the situation is related, among other, to the presence of systemic diseases and the treatment used, limitations in shaping proper dental health behaviors, insufficient knowledge of parents about oral health or barriers in access to dental care.
The development of recommendations for parents/caregivers as well as medical staff is required to improve the health of these patients and quality of their life. The document contains information on the etiology and epidemiology of dental caries in patients with disabilities but also prophylactic recommendations for this population of patients and their parents/caregivers and dentists.
Patients with reduced capacity due to mental, motor or sensory deficits are a population characterised by greater therapeutic needs compared to healthy individuals (1). Higher risk of morbidity in this group of patients requires preventive actions adjusted to their needs, also in the aspect of oral health problems.
The number of generally available, specialist dental offices for patients with disabilities is limited in Poland. These patients are often admitted to dental offices under the same conditions as healthy individuals (2). In some provinces, funds are allocated for the disabled as a part of public health care. It should be noted that the need for professional oral care in this patient population has been repeatedly emphasised worldwide.
According to Article 25 of the Convention on the Rights of Persons with Disabilities, which was adopted by the General Assembly of the United Nations on the 13th December 2006, “persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability” (3). The Convention was signed by the Polish government on the 20th March 2007 and ratified by Poland on the 6th September 2012 (4).
Furthermore, the FDI General Assembly held in Sydney (Australia) on the 18th September 2003 adopted a position on the dental care for persons with disabilities, which was also adopted by the Polish Dental Association (5). It was agreed that “oral health of disabled people should be ensured through education on oral health and prevention of oral diseases”, “cooperation with decision-makers and other interested parties should be a part of an overall strategy for the development and implementation of dental services for disabled persons”.
However, there are no guidelines allowing for detailed specification of the principles for preventive and therapeutic management that would serve as a basis for health programmes to be implemented in this group of dental patients.
The aim of the paper is to present the recommendations for the preventive and therapeutic dental care in patients with disabilities as well as their parents/caregivers and dentists. The work was based on a national and worldwide literature review concerning dental caries and its prevention in patients with disabilities.
The scale of the health problem
According to data from the World Health Organisation (WHO), more than 1 billion people (about 15% of world population) are affected by some form of disability (6, 7). Of those, 110-190 million (2.2-3.8%) of people over 15 years experience significant disabilities.
National data with comments was included in the report of the Central Statistical Office. It was noted that the information concerning persons with disabilities is derived from a number of statistical studies (8). However, due to the methodology used, the availability of data at a certain level of territorial division remains limited. So far, national census was the largest study to collect data regarding individuals affected by disability. The last National Population and Housing Census was conducted in 2011 and used a mixed method, i.e. administrative data sources, including registers and information systems, as well as data obtained directly from the population as part of a representative survey. Furthermore, it was stated that most data in the 2011 Polish Census, including information regarding disability, was derived from a representative survey performed in a 20% nationwide sample of randomly selected apartments, as well as on a voluntary basis. Hence, such an approach limits the availability of data at lower levels of territorial division (8). Such information can be treated as a basis for professional epidemiological studies.
Currently available data also indicates that the number of persons affected by disabilities is on the rise both in Poland and worldwide due to population ageing as well as an increased incidence of chronic diseases (6). Furthermore, significant development in medical sciences and technology as well as social facilities allows the survival of a significant percentage of people with disabilities (9), which should shape health policy to ensure proper quality of life for these individuals.
Oral health of people with disabilities
This patient population is characterised by higher caries rates.
In the years 2006-2007, a clinical evaluation of oral health in paediatric population with disabilities and a sociomedical study in their parents/caregivers were performed as a part of “Epidemiological assessment of oral health in disabled and chronically ill children” commissioned by the Ministry of Health in four Polish provinces: Greater Poland, Łódź, Podlasie and Lublin (10-12). The studied population was composed of individuals with moderate to severe intellectual disability, nervous system diseases (infantile cerebral palsy and epilepsy) and impaired sensory efficiency (poor vision and blindness). An assessment of dental health in 289 patients with mixed dentition showed caries incidence of 75.1% in the general population of these children, including 72.8% in the group with intellectual impairment, 76.1% among patients with nervous system diseases and 76.1% in patients affected by vision impairment and blindness (11). Caries intensity index (dmft + DMFT) was 5.3 in this population, and 4.8, 5.6 and 5.4, respectively, in the individual groups of patients. Among the total group of 499 patients with permanent dentition, the incidence of caries was 68.3%, and the intensity of caries (DMFT) was 6.5. The following values were obtained for different groups of patients, which were created based on health status: 70.3% and 6.7 in individuals with intellectual disability, 71.3% and 6.9 in patients with cerebral palsy and epilepsy, as well as 57.6% and 4.9 in adolescents with sensory dysfunctions (11).
Studies conducted by different authors both in Poland and worldwide indicate higher numbers of decayed and missing teeth as well as worse oral hygiene compared to healthy population (9, 13-16). Furthermore, dental-facial defects and impaired oral functions are reported for a significant percentage of these patients (17). However, it should be emphasised that there are significant differences in the oral health status in this group of patients depending on the type of disability and the presence of systemic comorbidities, as shown in epidemiological research.
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