Disabled People

Guidelines for
Oral Health Promotion & Intervention

for Disabled Population
Developed under
GOI - WHO Collaborative Program
(Biennium 08-09)
CENTRE FOR DENTAL EDUCATION & RESEARCH

All India Institute of Medical Sciences, New Delhi
I
Guidelines for Oral Health Promotion
& Intervention for Disabled Population
Research Team
Principal Investigator : Dr. Naseem Shah
Co-Investigators : Dr. Vijay Mathur
: Dr. Ajay Logani
Guidelines for
Oral Health Promotion & Intervention
for Disabled Population
CONTENTS
1. Preface 1
2. Executive Summary 2
3. Background and Objectives 5
4. Introduction 6
5. Oral Disease Burden among the Disabled 9
6. Issues in Oral Health Promotion & Intervention for 10
Disabled Population
7. Study for assessment of oral health care needs of the 12
Disabled persons, barriers and KAB survey of health
care professionals, school teachers and care givers.
8. Recommendations 17
a. Oral Healthcare Professionals
b. Disabled Subjects and their caregivers
c. Teachers in special schools
d. Policymakers
9. References 24
10. Annexure 26
I. Description of activities undertaken
II. List of Workshop participants
III. Tables of results of KAB Survey
5
PREFACE
The problems of disability and efforts to bring them to mainstream life are
difficult challenge for the society. The health professionals have constitutional
obligation to oversee that all people are treated equally in terms of healthcare
provisions, irrespective of their race, religion or disability. The health care for
People with Disabilities (PWD) is being stressed at suitable forums and work
places. However, oral health care has not been given due importance for the
PWD. The GOI-WHO Collaborative Programme took the initiative in this regard
to formulate “Guidelines for Oral Health Promotion, Prevention and
Intervention in Disabled Population.” The Centre for Dental Education and
Research, AIIMS was given the responsibility for this work. Accordingly, a work
plan was formulated by the Centre for Dental Education and Research (CDER),
at AIIMS, involving extensive literature search, studying of knowledge, attitude
and behaviour (KAB) of the dental professionals, primary care givers and
teachers of special education in various institutions and NGOs. Finally a
brainstorming session with different stakeholders was held and the
recommendations were formulated and circulated among the workshop
participants, Ministry of Health & Family Welfare and Ministry of Social
Justice and Empowerment in particular Sh. T. D. Dhariyal, Dy. Commissioner
(Disabilities) and WHO experts.
The final recommendations are compiled in this report. We dedicate this report
to the disabled population of our country with the sincere hope that this report
will pave the way for equal rights and opportunities for good Oral Health to the
disabled population.
We acknowledge the help and support of various schools and NGOs working in
the area of disability, which allowed us to interact freely with PWD and their
guardians. Our sincere thanks to all dental professionals who participated in
KAB survey and all the stakeholders who gave their valuable inputs during the
Brainstorming workshop conducted on 18th April, 2009 at CDER, AIIMS.
Finally we acknowledge the AIIMS administration for allowing us to undertake
the study and providing all the support during the course of the study. .
Dr. Naseem Shah
Dr. Vijay Mathur
Dr. Ajay Logani
1
Executive Summary
People with disabilities suffer in their day to day activities at home and
workplace. The amount of suffering or inconvenience is proportional to their
type and extent of disability. Oral health of these subjects is affected due to
difficulties in maintaining oral hygiene and in seeking dental treatment. They
generally have low expectations from the health profession and face immense
difficulties in accessing health care facility when the need arises. Health care of
disabled is also affected by their dependence on primary caregivers and
environmental factor like friendly access etc. Further, oral health is accorded
least priority thus compounding and compromising oral health care for the
disabled. Literature suggests that disables suffer more in terms of extent and
severity of oral health problems. Several studies have reported higher
prevalence of oro-dental diseases and lower oral health service utilization
among the disabled. In the western countries, there are several guidelines for
day to day oral health care and facilities for oral health services for the disabled.
However, there are no such guidelines for prevention and treatment of oral
problems for persons with disabilities in our country. This study aims to
evaluate knowledge, attitude, practices and day to day problems with respect to
oral health in such people. Finally it is aimed at finding solutions and drawing
guidelines for prevention and treatment of oral problems for persons with
disabilities.
The objectives of the study were as follows:
1. To find out the oral health care needs for persons with disabilities.
2. To identify the barriers which hinder them from seeking oral health
care.
3. To formulate guidelines for oral health promotion and interventions for
the disabled.
The disabled people do not form a homogenous group due to varying nature of
disabilities in different individuals. Therefore it was decided to study four
major categories i.e. Visually challenged, hearing challenged, Physical
handicap and mental conditions like cerebral palsy, mental retardation etc.
According to the recent data, there are 21.9 million disabled people in the
country, which constitutes about 2.13 per cent of the total population.
Many studies have reported high prevalence of dental caries and periodontal
conditions in persons with disabilities. Therefore the treatment needs of these
subjects are also very high. The dental health care providers lack training on
special needs of such patients, resulting in inadequate oral health care provision
2
to them. All the above listed factors lead to poor oral health and oral health care
in people with disabilities. It is required to find out the difficulties with
different categories of the disabled group with respect to oral health care and
then draw the guidelines. In general, disabled people with have poorer oral
health and oral hygiene than those without disability. Data indicate that people
who have some or other disability have more untreated caries and a higher
prevalence of gingivitis and other periodontal diseases than the general
population.
The persons with various developmental and physical disabilities have difficult
life and they have to cope up with extreme situations even for performing day to
day activities. The oral hygiene maintenance is a problem for most of them due
to physical disabilities and poor neuro-muscular coordination, especially in
mental retardation and mental illness patients. Oral health care utilization
among the disabled people is low due to several reasons, like poor accessibility
to health services, dependence on caregivers, lack of adequate training of health
care providers and their attitude and finally their own low expectations from
health care services
In order to take a feed back on the problems faced by subjects with different
disabilities in day to day oral hygiene maintenance and seeking oral health care
services, an interview based questionnaires was designed for the disabled, their
primary caretakers and schoolteachers. Another questionnaire was designed for
oral health care providers to find out about their knowledge, attitude, practices
and training in handling persons with various disabilities. They were also asked
to give their valuable suggestions.
It was found out that most of the subjects (88%) were cleaning their teeth but
61% required assistance from caregivers. Only 27% of them brushed twice daily
and 45% practiced rinsing after every meal. Forty percent of the subject had
suffered from some dental problem in the past. Only 8% of the disabled subjects
reported to be getting regular dental check ups through the school/ institution.
Of those who went to seek dental care, few reported difficulty in access,
communication and dentist’s hesitation to provide treatment.
The data on schoolteachers from special schools revealed that 79 % monitored
cleaning/ rinsing/ brushing in schools, where mid day meals were being
provided. Oral hygiene instructions were given by 36 % of the teachers during
assembly time. The analysis also revealed that there was a lack of mechanism
for regular dental check up of these children and most of the teachers were not
satisfied with the level of oral hygiene of school children.
The result of the profile of the dentists indicated that usually more than one person
accompanied a disabled person to the dental clinic. Most of them did not receive
3
any kind of special training to provide treatment to disabled persons. Majority of
them (79%) felt the need for general anesthesia to manage disabled children,
specially, the mentally retarded children, but only 1% of them actually used it.
A brainstorming workshop involving various stakeholders dealing with the
th
disabled person’s issues was organized at CDER, AIIMS on 18 April, 2009. The
aim was to get their perspectives in identifying the barriers and suggest
measures for improving oral health promotion, prevention and intervention for
the disabled population of the country. The recommendations of the workshop
was circulated to all the participants for their comments and finally compiled.
The major recommendations are divided in two components i.e for persons with
disabilities and dental health care providers. The implementation would
require multi pronged approach on behalf of several Ministries, Departments,
Institutions and professionals themselves at society level and at individual
level. There is an urgent need of generating oral health awareness among the
disabled, their primary caregivers and the schoolteachers using different
communication methods and mass media. They need to be empowered to take
care of their own oral health and maintain quality of life.
There is strong need to revise the curriculum for various dental health
professionals to train them in providing oral health care for persons with
disabilities. The Dental health professionals themselves should make positive
efforts to learn skills to handle PWD and provide them the best possible oral
care. They need to be proactive for oral health awareness generation among the
disabled. Finally, it is the major responsibility of different sectors in the
Government, to facilitate both; providing adequate opportunities and the
required funds for oral health of the disabled population.
4
Background and Objectives
People with disabilities face discrimination on various accounts; their physical
disability, behavior and attitude of the society at large and on socio-economic
grounds. As regards to their health, disabled persons themselves have low
expectation from the health profession. They also face immense difficulty in
accessing health care facility when they need it, in terms of environmental
barriers and behavior and attitude of their immediate care givers and health
professionals. Oral health is often accorded the lowest priority in the context of
overall health and therefore oral health of the disabled person is neglected in
view of both these factors combined together.
The Centre for Dental Education and Research, AIIMS has taken an initiative to
formulate the guidelines for oral health promotion, prevention and intervention
of the disabled subjects with financial support from Government of India - WHO
Collaborative Programme as their commitment towards welfare of the disabled
population.
The objectives of the study were as follows:
1. To find out the oral health care needs for persons with disabilities.
2. To identify the barriers which hinder them from seeking oral health care.
3. To formulate guidelines for oral health promotion and interventions for the
disabled.
15
Introduction
“Everyone has the right to a standard of living adequate for the health and well-
being of himself and his family, including medical care and necessary social
services.” (The United Nations Universal Declaration of Human Rights (1948)
Article 25)
The above declaration makes it very clear that everyone has equal right to good
health and well being, including persons with disability (PWD. The core values
of Human Rights law in the context of disability have defined the following
under its Inclusive policy & availability of services on equal basis:
• Non-discrimination: The dignity of each individual, who is deemed to be of
inestimable value because of his/her inherent self-worth, and not because
he/ she is economically or otherwise “useful”
• Autonomy and participation: The concept of autonomy or self-
determination, which is based on the presumption of a capacity for self-
directed action and behaviour, and requires that the person be placed at the
centre of all decisions affecting him/her;
• Equality of opportunity : The inherent Equality of all regardless of
difference;
• Inclusion : The ethic of solidarity, which requires society to sustain the
freedom of the person with appropriate social supports.
In 2001, WHO report published on “Rethinking care from the perspective of
Disabled people”, it was brought out that it was societies’ inability to
accommodate people with different needs and abilities which needed to
change rather than narrowly focus on limitations of the disabled people in the
context of health care provision. It was stressed that anti-discriminatory laws
were required for systematic removal of environmental and cultural barriers.
The core values outlined above and also reflected in the perspective from the
affected people (disabled) themselves should be central while framing policy
guidelines for disabled population in any sphere, as in oral health promotion,
prevention and care provision. It is the right of the disabled to have good oral
health as mush as any other and not given as charity.
Disability is difficult to define and interpret. Some are born with the disability
and some acquire it, later in life. It is an umbrella term, covering impairments,
activity limitations, and participation restrictions. Impairment is a problem in
body function or structure; an activity limitation is a difficulty encountered by
an individual in executing a task or action; while a participation restriction is a
6
problem experienced by an individual in involvement in life situations.
Disability could be mental or physical and their severity can differ in different
individuals. Thus disability is a complex phenomenon, reflecting an interaction
between features of a person’s body and features of the society in which he or
she lives.
Different definitions of disability have been proposed as follows;
Government of India, (Gazettee notification of Jan. 1, 1996) defines “person
with the disability” as a person suffering from not less than 40% of disability as
certified by a medical authority.
Australian Dental Association defines it as limitation, restriction or
impairment which have lasted or likely to last for 6 months or more.
British Disability Discrimination Act (BDDA), 1995 defines Disability as a
physical or mental impairment, which has a substantial and long-term adverse
effect on his/ her ability to carry out normal day-to-day activities.
International Labor Organization defines disabled person as “any person
unable to ensure by himself or herself, wholly or partly, the necessities of a
normal individual and / or social life as a result of deficiency, either congenital
or not, in his or her physical or mental capabilities”.
World Health Organization: International Classification of Impairments,
Disabilities and Handicaps (ICIDH) of 1980 was revised in 2001, referred to as
the ICIDH-2, is officially titled the
“International Classification of
Functioning and Disability.” The new
system explicitly contemplates an
assessment of “environmental factors,”
including the physical environment, the
social environment and the impact of
attitudes, and of “personal factors,”
which correspond to the personality and
characteristic attributes of an individual.
The disability types have been classified
into 5 categories:
I. Physical and Communication Disabilities
II. Mental, psychological illness and Mental Retardation
III. Learning Disabilities
IV. Multiple Disabilities
V. Medical Disabilities (MD):
7
Hence, disabled people do not form a homogenous group. They may be, the
physically disabled, mentally retarded, the visually, hearing and speech
impaired, with restricted mobility or with so-called “medical disabilities”,
learning disabilities or with multiple disabilities.
Census of disabled people in India
The Registrar-General of India recently released break-up figures for disability
following the analysis of Census 2001 figures.
According to the recent data out of 21.9 million disabled people in the country –
that constitutes about 2.13 per cent of the total population - 1.03 per cent are
visually impaired, 0.16 per cent speech impaired, 0.12 per cent ‘hearing’
impaired, 0.59 per cent ‘movement’ impaired and 0.22 per cent ‘mentally’
disabled of the total national population. However, Disability sector feels that
the Census result is highly underestimated. It claims that 5 % of population has
one disability or the other.
The 2001 Census figures show that the highest percentage (48.5%) of disabled is
in the visual impairment category followed by the disability in ‘movement’ (27.9
percent). The lowest percentage (5.8) has been reported for hearing disability.
It is the obligation of the state and its people to have inclusive, non-
discriminatory policies and programmes to provide equal autonomy and
opportunity to all. Health being central to well-being of any individual or the
society, it is important that health planning considers all sections of its people,
on equal footing.
Oral health is integral to overall health
and well being. It has a direct impact
on QOL. Oral diseases are universal
affecting large populations, especially
in developing countries, which can ill
afford the expenses involved for
curative treatment. In disabled
population, prevalence of oral
diseases is known to be higher, as
discussed in the next chapter.
Therefore, it is essential that special
attention is given to improve oral
health of disabled persons which can
have a very positive impact on their QOL and help them cope better with their
disability.
8
Oral Disease Burden among the Disabled
Good oral health can empower disabled persons and give them confidence to
reach their full potential. Poor oral health can adversely affect intake of nutritious
food, self image and confidence and can cause significant pain, which a disabled
person may not be able to communicate. Disabled persons should have the same
entitlement as any other in the population.
Many studies have reported high prevalence of dental caries and periodontal
conditions in persons with disabilities. Therefore the treatment needs of these
subjects are also very high. The dental health care providers lack training on
special needs of such patients, resulting in inadequate oral health care provision
to them. All the above listed factors lead to poor oral health and oral health care in
people with disabilities. It is required to find out the difficulties with different
categories of the disabled group with respect to oral health care and then draw the
guidelines.
In general, disabled people with have poorer oral health and oral hygiene than
those without disability. Data indicate that people who have some or other
disability have more untreated caries and a higher prevalence of gingivitis and
other periodontal diseases than the general population.
Periodontal Disease: Medications, malocclusion, multiple disabilities, and poor
oral hygiene combine to increase the risk of periodontal disease in disabled
people.
Dental Caries: The disabled people develop caries at the same rate as the general
population. The prevalence of untreated dental caries, however, is higher in
these people due to high carbohydrate diet, poor oral hygiene, inadequate
brushing, sometimes dry mouth, apertognathia, syndromes and oral habits like
mouth breathing etc.
Malocclusion: The prevalence of malocclusion in disabled people is similar to
that found in the general population, except for those with coexisting disabilities
such as cerebral palsy or Down syndrome.
Missing Permanent Teeth, Delayed Eruption and Enamel Hypoplasia: These are
more conditions common in people with mental retardation and coexisting
conditions than in other people.
Damaging Oral Habits: These are more commonly found in people with mental
retardation. Common habits include bruxism, mouth breathing, tongue
thrusting, self-injurious behaviour such as picking at the gingiva or biting the lips
and pica-eating; objects and substances such as gravel, cigarette butts, or pens
Trauma and Injury: Injuries to the mouth from falls or accidents are more
common in disabled people due to low stability, epilepsy etc. Further, physical
abuse is also reported more frequently in people with disabilities than in the
general population.
9
Issues in Oral Health Promotion & Intervention for Disabled
Population
Barriers to Oral Health and Hygiene

The persons with various developmental and physical disabilities have difficult
life and they have to cope up with extreme situations even for performing day to
day activities. The oral hygiene maintenance is a problem for most of them due
to physical disabilities and poor neuro-muscular coordination, especially in
mental retardation and mental illness patients. Oral health care utilization
among the disabled people is low due to several reasons, such as;
a. The accessibility to health services infrastructure is poor
b. They are dependent on caregivers for travel and
c. Health care providers are neither trained nor have attitude to tackle
them with patience and
d. Many institutions do not have facilities to handle such patients.
e. Disabled persons themselves have low expectations from health care
services
British Dental Association in their policy document on “Oral health care for
people with physical disability guidelines 2000” has outlined the barriers in
Oral health of disabled persons as follows:
a) Information, access and transport
b) Impaired mobility condition individuals have lower expectation of services.
c) Physical environment and architectural infrastructure are other barriers.
d) Upper limb disability (ex. Paraplegia) affects oral hygiene maintenance and
higher periodontal disease.
e) Chronic inadequate oral hygiene
practices delivered by health care
worker are reported.
f) Attitudes and knowledge of health
professionals and health care welfare
are identified as barriers to oral
health.
The available evidence indicates that
provider attitudes seem to be a constraint
on PWD access to health services.
10
Research from hospitals throughout Orissa found that less than 40 percent of
providers were aware of entitlements under the PWD Act, and that close to 40
percent of them considered PWD as a burden. In Gujarat, many village health
workers did not know that mental illness and retardation were disabilities. The
existence of attitudinal barriers receives support from the UP and TN survey
also, which found that 16 percent of PWD did not seek health services due to
provider attitudes. In addition, field research from Karnataka and Rajasthan
indicates a generally low level medical awareness among health care providers
of disability issues, in particular with respect to mental health. Finally,
articulation of demand by district and sub-national governments for health
services for PWD is poor.
Health seeking behavior
Evidence from NSS shows that
• Those disabled from birth are much less likely to seek care.
• Women with disabilities were somewhat less likely to seek care, and
even less likely to have assistive appliances.
• Regionally, access to care appears to be lowest in the North-East and
eastern regions, while
• Those in urban areas throughout India are much more likely to have
sought care.
• Higher levels of education substantially increase the access to health
care, as does co-residence of the person with disabilities with their
parents.
Socio-Economic Profile of Persons with Disabilities (PWD)
The National Sample Survey for 2002 estimates that 8.4 percent of rural
households and 6.1 percent of urban households had a member with a
disability. Large numbers of children with disabilities remain out of school.
They are 4 to 5 times less likely to be in school than SC/ST children. If they do
stay in school, they rarely progress beyond primary levels. PWD employment
rates were substantially below those of the general population in both urban and
rural areas and for both genders and this leads to lower living standards. The
families with disabled members tend to have lower family income due to more
number of hours spent by caretakers and bread-earners of the family for the care
of the disabled member. The NSS data also indicate that women with
disabilities have much higher rates of widowhood than women without
disabilities in both urban and rural areas, implying higher probabilities of being
poor.
11
Study for assessment of oral health care needs, barriers and
Knowledge, Attitude, Behaviour (KAB) survey of h e a l t h c a r e
professionals, school teachers and care givers.
In order to take a feed back on the problems faced by subjects with different
disabilities in day to day oral hygiene maintenance and seeking oral health care
services, an interview based questionnaires was designed for the disabled, their
primary caretakers and schoolteachers. Another questionnaire was designed for
oral health care providers to find out about their knowledge, attitude, practices
and training in handling persons with various disabilities. They were also asked
to give their valuable suggestions.
An Information Sheets was provided in Hindi as well as English to all subjects
before taking the informed consent in the Consent Form for participation in the
survey.
Results – Disabled subjects and caretakers
The main components of the questionnaire proforma for the disabled subjects
and their caretakers were on Oral hygiene practices, experiences during dental
health care and problems encountered during day to day care as well as during
service utilization. Apart from this, few extra questions were asked to caretakers
on the problems faced by them in daily oral hygiene maintenance for their
wards.
Distribution of sample
A total of 100 subjects from four different disabilities were included in the
survey ranging from 1.5 years to 62 years (mean 17 years). About 48 subjects
were either too young to reply or unable to reply, therefore the primary care
takers were the respondents. There were about 20% of subjects with more than
one disability in the sample. The distribution of subjects as per disability was
equal in mental retardation, blindness and locomotor disability. However,
subjects with speech & hearing disability were comparatively less.
Oral Hygiene Maintenance
Most of the subjects (81%) were cleaning their teeth on their own, with standard
toothbrush (88%) and toothpaste (86%). Only 27% of the subjects were found to
be brushing twice daily. Rinsing after every meal was done by 45% of the
subjects. Only children with mental retardation/ cerebral palsy had problems
in holding the brush, making cleaning movements, spitting and rinsing difficult
for them and required assistance.
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Dental Experiences
Forty percent of the subject had suffered from some dental problem in the past.
However, only 33% reported to a dentist for treatment. Only 8% of the disabled
subjects reported to be getting regular dental check ups through the school/
institution. Of the 26 who reported visit to a dentist, only 2 had problem in
access, 1 had problem in communication, 2 reported dentist’s non-acceptance
to treatment and 4 subjects had problems in getting dental procedure done on
them.
Problems faced by primary caretakers
The primary care takers reported that 62% of them were helping their wards in
cleaning teeth. However, the problems faced by the caretakers were
communication (29%), stabilization (33%), keeping the mouth open (42%),
making cleaning movements (38%) and making the child spit and rinse (63%).
KAB survey of teachers of special schools (Annexure)
The analysis revealed that the majority of teachers in special schools were
women; in approximate ratio of 2.5:1 (F: M). The average age was 35.5 years and
had 6 years of work experience on an average. Most of the teachers had either a
graduate or a postgraduate degree and 85% of them had received formal training
in handling differently abled persons.
Oral hygienic practices: 79 % of the teachers responded that they monitored the
children during cleaning/ rinsing/ brushing of their teeth in schools where mid
day meals were being provided. Oral hygienic instructions were given by 36 %
of the teachers. The mode was usually verbal and during assembly time.
Toothbrushes for the children were provided by 91 % of the school themselves.
The analysis also revealed that there was a lack of mechanism for regular dental
check up and most of the teachers were not satisfied with the level of oral
hygiene of school children. 75% of the teachers reported that student did have
dental problem/ pain during school hours. Communicating with the disabled
child and stabilizing them during brushing and making them spit & rinse,
compounded the maintenance of oral hygiene. The need for urgent attention to
oral health care for these children was expressed by 74% of the teachers.
KAB survey of Dental health care providers (Annexure)
The result of the profile of the dentists indicated that 75% of them were male in
the age group of 30.5 years, with a work experience of minimum four years and
had their practices based in urban setup. Following conclusions were drawn
from the responses to the questionnaire.
13
For Table
For Table
1. The persons who usually accompanied the disabled person to the clinic
were either or both parents. 50% of the dentists interviewed had received
some kind of special training to provide treatment to disabled persons, with
64% of them receiving it during their post graduation. The training
comprised of both theoretical as well as practical. But most of them (64%)
were not satisfied with the level of their training
2. Majority of them (79%) felt the need to manage the disabled children,
specially, the mentally retarded children under general anesthesia, but very
few of them actually used it.
3. Most of the dentists felt the need to use mouth props as one of the most
important aid in management of disabled persons.
5. Brainstorming Workshop
th
A brainstorming workshop was organized on 18 April, 2009 at CDER, AIIMS.
Various stakeholders dealing with the disabled person’s issues were invited to
get their perspectives in identifying the barriers and suggest measures for oral
health promotion, prevention and intervention for the disabled. (List of
participant enclosed as Annexure A).
After few brief presentations, a guided discussion was held in which each of the
participants was asked to present their viewpoint on the subject. In the
afternoon session, the participants were divided into four groups to formulate
the guidelines for oral health care professionals, persons with disabilities, their
caretakers and schoolteachers, for the policymakers and finally, use of mass
media and IEC development for various target groups. The recommendations of
the groups were compiled and circulated among the participants for comments.
The final recommendations are presented in the next chapter.
16
Recommendations
After thorough literature search, indepth discussions with various important
stakeholders, findings of KAB survey of the disabled subjects, their caregivers,
schoolteachers and dental health care providers and the brain storming
workshop, the recommendation were formulated for
- Disabled people, primary care givers and schoolteachers
- Dental Health care professionals
- Policy makers
A. RECOMMENDATIONS FOR DISABLED SUBJECTS AND THEIR CARE
GIVERS
1. Education on dental problems and risk factors.
a. Impact of Oral health on general health
b. Importance of regular check up
2. Oral hygiene instructions and demonstration
a. Method of brushing, use of electric toothbrush, special
modifications of toothbrush handle and special aids in oral hygiene
b. Use of topical fluoride and other anti caries and anti plaque agents
3. Dietary Instructions
a. Restrictions of sweets and sticky food
b. Promotion of healthy food and fibers
4. Information on available dental health care facilities in the vicinity
B. RECOMMENDATION FOR TEACHERS IN THE SPECIAL SCHOOLS
a. Training on oral health & hygiene
b. Training on early identification (signs & symptoms) of oral diseases
for early referral
c. Prevention of oro-facial trauma and first aid.
d. Information on available dental health care facilities in the vicinity
C. RECOMMENDATIONS FOR DENTAL HEALTH CARE PROFESSIONALS
The Dental Professionals should have attitude, behavior and
understanding of the special needs of people with disabilities. For this
certain measures are required for their capacity building as listed
below:
17
Capacity building of Oral Health care professionals
1. Modifying dental curriculum for UG/ PG and Dental Hygienists to
include didactic and hands-on training in provision of oral health
care to the disabled in institutions as well as in the community.
2. Short term courses (3weeks-3 months) can be initiated for dental
professionals to make them competent in handling PWD.
3. Continuing dental education (CDE) programmes on Oral Health
promotion, prevention and interventions for the PWD to develop
adequate skills and knowledge on providing oral care to PWD and it
can be attained via attending. The Institutions of excellence like
AIIMS and professional organizations like Indian Dental Association
etc. may be helpful in providing such training and CDEs.
Leadership role in community
1. Role as master trainer for disabled, caretakers, teachers and health
workers
2. Visit to special schools and institutions.
3. Formation of self-help groups and networking.
4. Use of mass media for creating awareness (radio talk, TV shows,
articles in print media etc.). Use of audio commentary for visually
challenged and written text for hearing impaired on oral health
related programs on visual media.
5. Demonstrations/ use of IT on oral health for educating policy makers,
health professional and general population, including disabled
persons and all other stake holders.
6. Liaison with NGOs working in the field of disability for spreading
awareness regarding oral health preventive measures oral health
care facilities available,
transport of disabled persons
to health care facility and
financial support.
7. Providing care through mobile
dental vans/ organizing camps
to provide service at the door
step of needy disabled
children, either in special
schools or in the community.
18
Training - Contents
1. Promotion of good oral health by lifestyle modifications related to
dietary practices and avoidance of harmful habits. (Tobacco, betel
nuts and quid, pan masala, alcohol etc.)
2. Training on oral hygiene maintenance by brushing
demonstration, modification of oral hygiene aids etc.
3. Prevention of oro-facial trauma and first aid.
4. Training on early identification (signs & symptoms) of oral
diseases for early referral
5. Information on available dental health care facilities in the
vicinity
IEC methods
IEC contents must be user friendly to the target audience.
i) For blind subjects, print medium should be in brail and electronic
messages should be with visual commentary
ii) For hearing impaired subjects, the messages must be more pictorial
and clear with text commentary.
iii) For mental retardation subjects, the IEC must be simple and at their
comprehension level.
iv) For orthopedically challenged subjects, IEC material and methods
should be the same as used for general population.
In general, print media may be prepared according to the disability category and
distributed through the institutions, schools and NGOs working in the area. The
electronic media can be specially prepared videos/ audios and slide
presentations. The use of website and
electronic discussion forums can also be
helpful for computer literate subjects
Creating barrier free environments
For the People with Disabilities, to be able
to access and utilize oral health care
services, it is of utmost importance to
create barrier free environment both in
the private set up as well as in the
Hospitals.
19
I. For clinics
a. Access to clinic
b. Open space in the clinical area for maneuvering of wheel chairs
c. Adjustable dental chairs
d. Stabilizing devices
e. Trauma protection devices
f. Provision for pharmacotherapy, conscious sedation and GA
facilities (optional but desirable)
II. For hospitals
• Disable friendly toilets, lifts, ramps etc.
• Door and window design should be disable friendly
• Electrical switchboards and panels etc at lower level
• Ease of access – distance
• Parking facilities – closer to entry/ exit
• Separate queue/ priority registration
• Centralized investigation facilities
20
Use of restraint/ protective stabilization
The term medical immobilization, protective stabilization and physical
intervention can be substituted for the term restraints. It helps to differentiate
behavioural restraint from medical/dental restraint for treatment. It is used for
patient and staff safety and to deliver effective oral health care.
Policy statement* on use of protective stabilization (Physical and
chemical) as follow:
It is a valid treatment modality for non-compliant developmentally
disabled patient.
- When using, the least restrictive should be used
- Should not be used solely for convenience of dentist or punishment
for uncooperative patient
- Should cause no physical injury and least possible physical
discomfort.
- The reason for use, type of treatment and length of time must be
recorded.
*Academy of Dentistry for persons with the Disabilities in its document on “Legal, ethical and medical consideration for use
of restraints in delivery of oral health care”
In certain cases of disability such as mentally challenged children, use of

concious sedation or general anaesthesia may be required to provide adequate
oral health care, but it should be used with discretion and in a facility well-
equipped to handle any medical emergency.
C. Recommendations for Policy makers
1. Ministry of Social Justice and Welfare
It’s PWD Act 1995 already define several measures for overall welfare of
disabled persons. Besides these, being the nodal agency looking after
the welfare of the disabled population of the country, the Ministry can
give guidelines and make recommendations to other concerned
ministry for facilitating oral health promotion, prevention and
interventions of the disabled as follows:
a. Ministry of Information & Broadcasting
• For commissioning oral health education programs, giving
primetime slot and free airtime for such programmes.
• Use of other mass media like newspapers and radio
21
b. Ministry of Education
• To incorporate lessons in curriculum of secondary school
education, college and higher education for sensitization
towards the special needs of disabled persons
• Use of electronic media (IGNOU) for spreading oral health
awareness of disabled, their care takers, school teachers
• To include oral health issues of disabled in the curriculum of
Master of Sociology, Psychology, Social Welfare etc
c. Ministry of Urban & Rural Development
• To ensure that all new hospitals, medical, dental and nursing
colleges are constructed to create barrier friendly environments
• In the existing facilities, modifications are made to make them as
barrier free as possible.
• Strict monitoring for compliance
2. Ministry of Health and Family Welfare
Using existing health care infrastructure, the health workers can be
trained in basic pain relief, identification of oro-dental problems and
referral with regard to oral health. The existing dental health care
facilities in PHC/ CHC / District hospital can be made disabled friendly
and the dental professional working there may be trained to cater to the
special needs of the PWD.
a. To promote oral health care access to disabled population
i. Make barrier free environments at all Government dental health
facilities.
ii. Make provision for certification of “Disabled friendly” nursing
homes, private dental colleges and clinics.
iii. Make Oral health care facility available at PHC level in order to
make oral health available at doorstep of needy disabled
persons (minimize travel distances for the disabled)
b. For capacity building and research regarding oral health care related
issues.
i. Inclusion of module for various health workers under NRHM on
disabled persons’ oral health
22
ii. To include oral health issues in curriculum of medical, dental,
nursing, AYUSH and other paramedical courses
iii. To promote research in oral health surveillance, promotion,
prevention and interventions for the special needs, disabled
population
c. Provision for special budget allocation for oral health care of
disabled from the oral health care budget.
i. Concessional rates / priority in Govt. hospitals
ii. Develop Public-Private Partnership (PPP) for oral health service
provisions by reimbursement of treatment costs.
iii. Health insurance and finances for oral health care provision for
the disabled
d. Development of sustainable models for provision of oral health care
for Institutions and for home-bound disabled persons.
e. Provision of oral health services at special schools and institutions
for the disabled. The same service can also provide services to other
such institutions nearby.
Recommendations for Dental Council of India
• To include a module on oral health for the disabled in the dental
curriculum at UG/ PG and Dental Hygienists etc.
• Implement and monitor rules for disabled friendly premises for
students and patients as per GOI guidelines.
23
References
1. The Persons with Disabilities (Equal Opportunities, Protection and Rights
and Full Participation) Act 1995. Gazette of India. Dated January 1, 1996,
Ministry of Law Justice and Company affairs, Govt. of India. New Delhi
1996. India
2. Bupinder Zutshi, Disability Status in India - Case Study of Delhi
Metropolitan Region. New Delhi, India. 2004
3. Guidelines for oral health care for people with a physical disability. British
Society for Disability and Oral Health. January 2000. As cited on
http://www.bsdh.org.uk/guidelines/ physical. pdf
4. Census of India 2001. Office of Registrar General and Census Commissioner
of India Govt of India.2001. As cited on http://www.censusindia.gov.in/
5. Country Profile on Disability, INDIA. Japan International Cooperation
Agency Planning and Evaluation Department. March 2002. A World bank
Report as cited on http://siteresources.worldbank.org/DISABILITY/
Resources/Regions/South%20Asia/JICA_India.pdf
6. Armour BS, Swanson M, Waldman HB, Perlman SP. A profile of state-level
differences in the oral health of people with and without disabilities, in the
U.S., in 2004. Public Health Rep. 2008 Jan-Feb; 123(1):67-75.
24
References for prevalence studies on
Oral Health of disabled population
1. Gupta DP, Chowdhury R, Sarkar S. Prevalence of dental caries in Disabled

children of Calcutta. J Indian Soc Pedod Prev Dent. 1993; 11(1):23-7.
2. Bhavsar JP, Damle SG Dental caries and oral hygiene amongst 12-14 years'
old Disabled children of Bombay, India. J Indian Soc Pedod Prev Dent. 1995;
13(1):1-3.
3. Dinesh RB, Arnitha HM, Munshi AK. Malocclusion and orthodontic
treatment need of Disabled individuals in South Canara, India. Int Dent J.
2003; 53(1):13-8.
4. Ivanciæ Jokiæ N, Majstoroviæ M, Bakarciæ D, Kataliniæ A, Szirovicza L.Dental
caries in disabled children. Coll Antropol. 2007; 31(1):321-4.
5. Vigild M, Skougaard M, Hadi RA, al-Zaabi F, al-Yasseen I. Dental caries and
dental fluorosis among 4-, 6-, 12- and 15-year-old children in kindergartens
and public schools in Kuwait. Community Dent Health. 1996; 13(1):47-50.
6. Al Sarheed M, Bedi R, Alkhatib MN, Hunt NP. Dentists' attitudes and
practices toward provision of orthodontic treatment for children with visual
and hearing impairments. Spec Care Dentist. 2006; 26(1):30-6.
7. Vyas HA, Damle SG. Comparative study of oral health status of mentally
sub-normal, physically Disabled, juvenile delinquents and normal children
of Bombay. J Indian Soc Pedod Prev Dent. 1991 Mar;9(1):13-6.
8.Bhowate R, Dubey A. Dentofacial changes and oral health status in
mentally challenged children.J Indian Soc Pedod Prev Dent.2005
Jun;
23(2):71-3.
25
Annexure - I
Description of Activities undertaken :
1. Extensive literature search - Policy documents of WHO, FDI, Ministry of
Health and Family Welfare, Ministry of Social Justice and Empowerment
and dental literature from the world over were consulted.
2. Interviews with policy makers - Focussed group discussions were held with
policy makers at different levels to find out various policies and documents
prepared for the disabled. The issues related to access to health care and
special provisions for the disabled with the respect to economic support etc.
were discussed. The Health related issues and programs for prevention of
various non communicable diseases, nutrition etc. were also discussed.
3. Case studies – Formal and informal interactions with disables persons, their
primary caregivers, teachers in specials schools for the disabled people were
undertaken in different schools and instituions. Oral Health Interventions
for the persons with disabilities at the dental health care facility as a part of
study of feasibility and difficulties in provision of oral health care. They
were asked about difficulties faced during day to day oral hygiene
maintenance, problems faced during visit to dental health care facilities like
accessibility, operating room modification and limitations in utilization of
health care. The teachers in the special schools for the disabled and trainees
in the vocational training institute for the purpose were also asked about
oral health knowledge, methods of prevention and barriers in promotion of
oral health in the subjects.
4. Knowledge, attitude and behaviour (KAB) survey of dental health care
providers regarding care of the disabled. – The knowledge, attitude and
behaviour of dental health care providers was undertaken using a structured
questionnaire covering their knowledge about various aspects of oral health
care provisions for the disabled like access to the facility, modifications
required in the operatory, appointment schedule and the procedures.
5. Brainstorming for formulation of the guidelines- The investigators drafted
guidelines with help from relevant experts for the disabled for oral hygiene
for themselves as well as primary caretakers and also for the dental health
care providers with respect to oral health promotion and interventions for
the disabled people. A brainstorming meeting was organized with various
stakeholders to finalize the draft guidelines prepared as above. The
following were included:
26
a) Rehabilitation experts
b) Teachers in special care schools
c) Social scientist
d) Dental professionals
e) NGO representatives
f) Public health experts
g) Health education specialist
Apart from this, representatives from Ministry of Health and Family Welfare,
WHO, Ministry of Social Justice and Empowerment and other relevant
departments were also invited.
27
Annexure - II
th
List of Workshop participants in the Brainstorming Meeting held on 18 April
2009 at Centre for dental Education and Research, AIIMS, New Delhi.
S. No. Name
1. Sh. T. D. Dhariyal, Dy. Chief Commissioner (Disability), Ministry of
Social Justice and Welfare
2. Mrs. Madhur Bhandari, Akshay Pratisthan (School for
Orthopedically challenged, providing Physio & Occupational
therapy and vocational training)
3. Dr. N. Laisram, Associate Professor of Physical Medicine and
RehabilitationSafdarjung Hospital(Addl. DG Nominee)
4. Sh. Deependra Manocha, Representative of PWD & Activist, National
Association for the Blind, CEO, DAISY for All (NGO working for
using Digital technology for the blind)
5. Dr. K. Rajan, Non Communicable Diseases & Mental Health, WHO-
India
6. Dr. Jitender Aggarwal, Representative of PWD, Activist & Dental
Surgeon
7. Dr. Anil Kohli, President, Dental Council of India
8. Dr. Mahesh Verma, Director-Principal, Maulana Azad Institute of
Dental Sciences, New Delhi
9. Dr. Sanjay Tewari, Principal, Govt Dental College, Rohtak
10. Dr. Manju Vatsa, Principal, Nursing College, AIIMS
11. Dr. Manju Mehta, Professor of Psychology, AIIMS
12. Mrs. Madhu Grover, Teacher, Special Education, Action for Ability
Development and Inclusion (AADI)
13. Dr. Jagdish Kaur, Chief Medical Officer, Dte.GHS, Govt. of India
14. Dr. Nikhil Grover, Pediatric Dentist
15. Shri Rupinder Singh, Parent of child with multiple disabilities
16. Dr. S.G. Damle, Pedodontist & Vice-chancellor, MM University,
Ambala, Haryana
28
17. Mrs. Madalsa Mathur, Activist, MUSKAN (NGO working for socially,
economically and physically affected children)
18. Dr. O.P. Kharbanda, Professor, CDER
19. Dr. Ritu Duggal, Addl. Prof.,CDER
20. Dr. Ajoy Roychoudhary, Assoc. Prof., CDER
21. Dr. Veena Jain, Assoc. Prof , CDER
22. Dr. Ongkila Bhutia, Assistant Prof., CDER
23. Mr. Dilshad Ahmed, Dental Hygienist, CDER
24. Dr. Ajay Logani, Asst. Professor, CDER and Co-Investigator
25. Dr. Vijay Mathur, Asst. Professor, CDER and Co-Investigator
26. Dr. Naseem Shah, Professor & Chief, CDER and Principal Investigator
29
I. Result of KAB survey of Disabled Subjects
Median age (range) 17 years 6 patients with primary disability of blindness had
(1.5-62) secondary disability (mental retardation-5,
Gender (%) locomotor-1;
Male 73 (74.5%) 1 patient with primary disability of
Female 25 (25.5%) speech/hearing had locomotor disability.
Category of Disability (%) Note : A total of 98 subjects had provided the
Mental retardation 26 (27%) responses; however not everybody had answered
Blindness 29 (31%) all the questions. Data Not Known (DNK) has been
Speech/Hearing 12 (13%) included for all such cases to keep the total as 98.
Locomotor 28 (29%) However the % have been calculated by using the
DNK 03 total number of responders for that questions as
Secondary Disability (%)* 18 (19%) denominator.
Cleaning of Teeth (%) Brushing Frequency (%)
Self 81 (84%) Less than once a day 04 (4%)
Require assistance 16 (16%) Once a day 67 (69%)
DNK 01 Twice a day 26 (27%)
Tool for Cleaning the Teeth (%) DNK 01
Tooth brush 88 (94%) Problem Areas (%)
Finger 03 (3%) Holding the tooth brush 07 (10%)
Both 03 (3%) Making cleaning movements 10 (15%)
DNK 04 Spitting out tooth paste 05 (8%)
Type of Toothbrush Rinsing 05 (8%)
Standard 86 (99%) Rinsing of Mouth after Every Meal (%)
Standard & Motorized 01(1%) Always 43 (45%)
DNK 11 Sometimes 36 (38%)
Material for Cleaning the Teeth (%) Never 16 (17%)
Tooth paste 83 (89%) DNK 03
Tooth powder 09 (10%) Satisfaction with Oral Hygiene level (%)
Both 01 (1%) Satisfied 66 (69%)
DNK 05 Non-satisfied 30 (31%)
Type of Tooth paste (%) DNK 03
Fluoride 32 (67%) Reason for Non-satisfaction (%)
Non-fluoride 17 (33%) Never told to clean teeth 01 (3%)
DNK 30 Cannot hold the tooth brush 02 (7%)
* 12 patients with primary disability of mental Bleeding while cleaning teeth 01 (3%)
retardation had secondary disability (blindeness- Diet Frequency (%)
10, locomotor-2); Two times a day 14 (29%)
30
Three times a day 33(67%) Dentist acceptance to 02 (8%)
Four times a day 02 (4%) providing treatment
DNK 49
Problem with the Teeth (%)
Yes 39 (40%)
No 59 (60%)
Frequency of Visiting a Dentist (%)
Always 11 (14%)
Sometimes 15 (19%)
Never 53 (67%)
DNK 19
Regular Dental Check-up (%)
Yes 07 (8%)
No 86 (92%)
DNK 05
Problem Areas (%)
Access to the dentist/hospital 02 (8%)
Communication with 01 (6%)
the dentist
KAB : Knowledge, Attitude & Behaviour
31
II. Result of KAB survey of Teachers of Special Schools
Median age (range) 35.5 years Presence of a method by which children are
(19 - 47) being given instructions on oral health care(%)
Gender (%) Yes 12 (36%)
Male 03 (9%) No 21 (64%)
Female 31 (91%) DNK 01
Qualification (%) Presence of a mechanism of dental check up

Graduate 10 (48%) periodically
Post-graduate 11 (52%) Yes 11 (32%)
DNK 13 No 23 (68%)
Specialized in handling differently abled Problem area (%)

people (%) Communicating with students 23 (67%)
Yes 29 (85%) Stabilizing the students for 22 (65%)
DNK 05 (15%) rinsing
Keeping the mouth open 25 (74%)
Median years in profession 6 years for students
(range) (0.2 – 24 ) Making cleaning movements 24 (71%)
Type of school/institution (%) Making the child spit and rinse 21 (62%)
Inclusive 32 (94%) Satisfaction with the level of oral hygiene of
Exclusive 00 the school children
DNK 02 Yes 07 (22%)
Mid day meal to the students (%) No 25 (78%
Yes 27 (79%) DNK 02
No 07(21%) Student having dental problems/pain in school
Monitoring of cleaning of teeth in general (%) Yes 22 (73%)
Yes 27 (79%) No 08 (27%)
No 07(21%) DNK 04
Monitoring of rinsing after meals/brushing in Suggestions
the school (%) Improving oral health of 20 (59%)
Yes 27 (79%) disabled children
No 07(21%) Improving oral health care 25 (74%)
Providing of oral hygiene aids like brush to services for these children
students by school
Yes 31 (91%)
No 03 (9%)
KAB : Knowledge, Attitude & Behaviour
32

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Guidelines for

Oral Health Promotion & Intervention

CENTRE FOR DENTAL EDUCATION & RESEARCH

Barriers to Oral Health and Hygiene

In certain cases of disability such as mentally challenged children, use of

1. Gupta DP, Chowdhury R, Sarkar S. Prevalence of dental caries in Disabled

KAB : Knowledge, Attitude & Behaviour

Qualification (%) Presence of a mechanism of dental check up

Specialized in handling differently abled Problem area (%)

KAB : Knowledge, Attitude & Behaviour

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