A learning disability is a lifelong condition affecting a person’s intellectual ability and may impair their capacity to undertake everyday activities, like brushing their teeth or visiting the dentist, independently. Although individual abilities vary, people with a learning disability may need support to develop new skills, understand complicated information and interact with other people.[i]
It is estimated that over a million people in England have a learning disability. Of those, around 905,000 are over 18, and 286,000 are children.[ii] Although services, including community dental services, exist to support adults with learning disabilities, it is estimated that only 20% of learning-disabled adults in the UK use these services, and many adults may not receive any assistance with the daily challenges they face.[iii]
People with learning disabilities have worse health outcomes in general than non-disabled people.[iv] Studies have found that people with intellectual disabilities are significantly more likely to suffer from edentulousness, and have worse oral health overall.[v] There are several contributory factors cited; adults with learning disabilities have a lower uptake of screening services,[vi] and may struggle to adhere to treatment or hygiene recommendations where memory or cognition is affected.[vii] Some medications may be a contributory factor – antipsychotics prescribed to some people with learning disabilities may increase the risk of xerostomia, for example.[viii]
A nationally coordinated survey of specialist schools concluded that a much higher percentage of children from 5 to 12 years with Special Educational Needs in the UK had experienced dental caries than children in mainstream schools. Of these, each had on average 3.9 affected primary teeth. Six per cent of 5-year-olds had one or more teeth extracted on one or more occasions, across England. This figure is approximately double that found among children attending mainstream schools.[ix]
Degrees of impairment require different approaches or support from family or paid carers. Where individuals do have dedicated support, they may still struggle to manage their oral care, including dental visits and managing adherence to treatments. Additional support for carers is recommended.[x]
The right to participate
A more person-centred approach to the treatment of learning-disabled people has emerged in the last 30 years, with the introduction of the Disabilities Discrimination Act (DDA) (1995), then the Equalities Act (2010), alongside developments in Human Rights legislation.[xi] The Mental Capacity Act 2005 outlines in its Code of Practice 2007 that although a person may lack the capacity to make certain decisions about complex matters, where they do have capacity, they should be allowed to participate in decision-making.[xii]
The social model of disability was first introduced in the 1980s, and identifies the importance of removing barriers to enable disabled people to participate in society rather than focusing on a person’s illness as the problem.[xiii] Dental practices are tasked with making reasonable adjustments to remove barriers to equal treatment.[xiv]
Codes of practice around the treatment of children and adults with impaired intellectual capacity increasingly encourage seeking participation from and collaboration with the person undergoing treatment wherever possible. To support the delivery of adjusted, person-centred care, the evidence shows a need for clinicians to undertake special training, and to utilise a number of different strategies to encourage understanding and participation. This is important for family carers, paid supporters, dental professionals and their staff teams, as well as for people with learning disabilities themselves.[xv]
People with learning difficulties can experience a high level of anxiety in a consulting room, and this can be a real barrier for patients in participating in their treatment. Communication skills that help with building a rapport, and resources that provide a distraction, like workbooks or tactile objects, can be helpful.[xvi]
Public Health England recommends that people with learning disabilities are involved in delivering training for the dental team. This has the additional advantage of providing teams with real-life experience.[xvii]
Seeking understanding
A person must be assumed to have capacity unless it is established otherwise, but even if they don’t, their participation in decisions affecting their own welfare is still important wherever possible. According to the Mental Capacity Act 2005, efforts must be made to include people in decisions until all practicable steps have been taken without success.[xviii] Consent is a process, not a one-off event, and it is important that there is continuing discussion to reflect the evolving nature of treatment.[xix]
Clinicians can make use of technology to assist patients in understanding the nature and purpose of certain treatments. Chairsyde – a state-of-the-art patient consultation platform – helps dentists to improve patients’ understanding of treatments. The system uses patient-friendly dental animations to demonstrate the benefits as well as the risks of all treatment options. Visualising treatment additionally supports patients who might struggle with different cognitive abilities. Chairsyde is recognised and recommended by dental industry leaders to support patients in committing to and participating in ongoing dental care.
Every practitioner is required to make genuine efforts to help patients understand their options before seeking consent, at every stage of treatment.[xx] Where there are impairments in understanding, it is the responsibility of clinicians to make adjustments to enable people to participate in decisions around their own care, and there are lots of resources out there to make this easier.
For more information, or to book a Chairsyde demo, please visit www.chairsyde.com
or call 020 3951 8360
[i] https://www.mencap.org.uk/learning-disability-explained/what-learning-disability#:~:text=A%20learning%20disability%20is%20to,someone%20for%20their%20whole%20life.
[ii]https://webarchive.nationalarchives.gov.uk/ukgwa/20160704171409/http://www.improvinghealthandlives.org.uk/publications/1063/People_with_Learning_Disabilities_in_England_2011
[iii] Faculty of Dental Surgery, The Royal College of Surgeons of England. Clinical Guidelines and Integrated Care Pathways for the Oral Health Care of People with Learning Disabilities. 2012. 2
[iv] Emerson E, Hatton C, Baines S, Robertson J. The physical health of British adults with intellectual disability: cross sectional study. Int J Equity Health. 2016 Jan 20;15:11. doi: 10.1186/s12939-016-0296-x. PMID: 26791808; PMCID: PMC4719222.
[v] https://www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities
[vi] file:///Users/writer/Downloads/guidelines_peoplewithlearningdisabilities_2012.pdf
[vii] chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.nidcr.nih.gov/sites/default/files/2017-09/practical-oral-care-intellectual-care.pdf
[viii] Kinnear D, Allan L, Morrison J, Finlayson J, Sherriff A, Macpherson L, Henderson A, Ward L, Muir M, Cooper SA. Prevalence of factors associated with edentulousness (no natural teeth) in adults with intellectual disabilities. J Intellect Disabil Res. 2019 Dec;63(12):1475-1481. doi: 10.1111/jir.12628. Epub 2019 May 6. PMID: 31062460.
[ix] chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://assets.publishing.service.gov.uk/media/6051f994d3bf7f0453f7b9a9/Inequalities_in_oral_health_in_England.pdf
[x] https://www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities#oral-health-of-people-with-learning-disabilities Kinnear D, Allan L, Morrison J, Finlayson J, Sherriff A, Macpherson L, Henderson A, Ward L, Muir M, Cooper SA. Prevalence of factors associated with edentulousness (no natural teeth) in adults with intellectual disabilities. J Intellect Disabil Res. 2019 Dec;63(12):1475-1481. doi: 10.1111/jir.12628. Epub 2019 May 6. PMID: 31062460.
[xi] https://lordslibrary.parliament.uk/disability-discrimination-act-1995-and-now/
[xii] chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpgacop_20050009_en.pdf
[xiii] Anna Lawson & Angharad E. Beckett (2021) The social and human rights models of disability: towards a complementarity thesis, The International Journal of Human Rights, 25:2, 348-379, DOI: 10.1080/13642987.2020.1783533
[xiv] https://www.legislation.gov.uk/ukpga/2010/15/section/20
[xv] https://www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities#oral-health-of-people-with-learning-disabilities
[xvi] https://www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities#oral-health-of-people-with-learning-disabilities
[xvii] https://www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities#oral-health-of-people-with-learning-disabilities
[xviii] chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpgacop_20050009_en.pdf
[xix] Faculty of Dental Surgery, The Royal College of Surgeons of England. Clinical Guidelines and Integrated Care Pathways for the Oral Health Care of People with Learning Disabilities. 2012. 69
[xx] https://standards.gdc-uk.org/pages/principle3/principle3.aspx
