Intellectual impairment Flashcards
What is the MENCAP definition of Learning disability?
- Reduced intellectual ability and difficulty with everyday activities which affects someone for their whole life
- E.g. household tasks, socialising or managing money
What 3 areas doe DSM define Intellectual disability as?
- Social skills
- Conceptual skills
- Practical skills
What IQ does WHO classify severity of intellectual disability?
Mild - IQ range 50-69
Moderate - IQ 35-49
Severe - IQ 20-34
Profound - IQ under 20
What two areas are affected with intellectual disability?
- Intellectual functioning e.g. learning and judgment
- Adaptive functioning e.g. activities of daily life like communication
What percentage of the population are Intellectual disability?
- 1% of pop
- Of those 85% have mild intellectual disability
- Makes more likely than females
What labels would you use to describe learning disability?
- Person with an intellectual impairment
- Person with a learning disability
- Person with a learning difficulty
Person/ people first
What is impairment? *Exam
- In context of health experience Impairment is any loss or abnormality of psychological, physiological or anatomical structure or function
- Impairment considered to occur at level of organ or system function
What is disability?
- In the context of health experience a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in manner or within range considered normal for a human being
What does WHO classify activity limitation as?
- Difficulty encountered by individual in executing task or action
What does WHO classify participation restriction as?
- a problem experienced by an individual in involvement in life situations
What are the causes of Learning disability?
- Preconception (Parental genotype, maternal health)
- Pre-natal (Chromosomal genetic, infection)
- Perinatal (Prematurity injury)
- Postnatal (Untreated genetic disorders, infection, trauma)
What are some syndromes associated with learning disability?
- Downs Syndrome
- Prader Willi Syndrome
- Angelman Syndrome
- Autism Spectrum Syndrome
What is Down’s syndrome?
- Most common due to full trisomy of chromosome 21 (95%)
What is the greatest risk factor for DS?
- Advanced maternal age
- Women over age of 35 and continues to increase
What other medical features are present with Down’s syndrome?
- Congenital Heart Defects
- Alzheimer’s Dementia
- Epilepsy
- Leukaemia
- Hearing impairment
- Diabetes Mellitus
- Ceoliac Disease
- Thyroid Disease
- Intellectual Impairment
Why are people with Down’s syndrome more likely to get periodontal disease?
- Oral hygiene reduced
- Oral function reduced
- Impaired migration of gingival fibroblasts
- Periodontal pathogens
- Saliva
- Impaired neutrophil chemotaxis
- Unregulated production of inflammatory mediators
What are some presentations of Prader Willi?
- Chromosome 15
- 1 in 15,000 affected
- Desire to eat food all the time
- Resticted growth leading to short stature
- Reduced muscle tone (hypotonia)
- Learning difficulty (but may have lack of normal IQ)
- Lack of sexual development
- Behavioural problems like tantruma
What is ASD/ASC?
- Complex developmental condition, behaviourally defined, that includes a range of possible developmental impairments in reciprocal social interaction and communication, and also a stereotyped, repetitive or limited behavioural repertoire.
- Sensory differences may also presenting feature
- Very common
ASD/ASC and dentistry?
- Sensory atypia is barrier to treatment
- Many hypersensitive to multitude of stimulus
- Toothbrushing and prevention has multiple sensory triggers
Who is included in the Learning disability team?
- Medical Dr
- Psychiatry
- Social Work
- Specialist nurse
- Occupational therapy
- Nutrition/dietician
- SLT
How should dental services be provided?
- Recognise everyone as individual
- Recognise everyone has right to participate in decision that affects lives
- Provide amount of support necessary to enable everyday living, including adequate health acre
What are some individual characteristics that are barriers for oral healthcare?
- Limited mobility to brush teeth
- Sensory problems don’t like being touched
- Dependent on carers or family members
- Females have higher anxiety
What are some access issues that are barriers for oral healthcare?
- Not having reg dentist
- Hard to get NHS dentist
- Cost
- Long delays for more complex needs
What are some other barriers for oral healthcare?
- Difficult to communicate
- Dentists unconfident with people with LD and don’t want to treat
- Transition between children and adult hard to process
How can we help people with lD with getting to the surgery?
- Preparation *
- Social stories ( ASD)
- Hospital / Health Passport
- Pre-visit (Scout the place out)
- Multiple visits with slow progress
- Liaise with Community Disability Nurse / Team for help
How can visual supports be useful for people with LD?
- Individuals with autism often benefit from
visual supports and schedules. - The following visual schedule outlines the
steps necessary for a dental visit.
What should you do on arrival?
- Give yourself time
- Start away
- Do best time of day for the patient
- Limit time spent in waiting room
How can someone communicate pain if not verbal?
- Aggression to you or them
- Altered facial expression
- Changes to mobility or balance
- Change in behaviour like irritability
- Change’s to appetite
- Confusion
What can you use to help you with communication of nonverbal patient?
- Pain communication toolkit
What are adjuncts to communication you can use?
- Makaton
- Picture Boards
- Letter Boards
- Talking Mats
- Draw
- Write
How can you create the right atmosphere?
- Non threatening environment
- Friendly
- Acclimatise with multiple visits
- Consider relaxation techniques
- Make it fun
- Don’t lose control
What to do on first visit?
- Keep it simple
- Don’t expect too much (dentist and patient)
- Building trust and relationships
When should clinical holding take place?
- Only considered if failure of other techniques
Only take place if
- Patient consents
- No capacity and deemed as benefit
- Unplanned emergencies where any pt presents risk
- Always record in notes and justify
- Benefit and in best interests
What are people with LD more likely to have in relation to oral disease?
- Less research within primary care
- More likely to have filled teeth, fewer extractions, more untreated decay than more profound disabilities
- Fewer dentures provided
- Increased burden of denture related problems
- Untreated tooth decay more likely
What are some risk factors of oral disease for people with LD?
- Frequent sugar intake
- Prescription of medications that can reduce saliva flow or increase gingival inflammation
- Gastroesophageal reflux
- Lower income and educational levels
- Difficulty in accessing dental services
- Being non-oral feeders
- Reduced dexterity resulting in ineffective tooth brushing
- Sensory sensitivity, making it difficult to co-operate with oral care
- Difficulty in understanding the importance of daily oral care
- Poor motor control
- Medications
- Rewarding – less common
- Higher levels of gum (periodontal) disease
- Greater gingival inflammation
- Higher numbers of missing teeth
- Increased rates of toothlessness (edentulism)
- Higher plaque levels
- Greater unmet oral health needs
- Poorer access to dental services and less preventative dentistry
What is self-injurious behaviour linked to?
- Cerebral Palsy
- Autism
- Tourettes
- Lesch-Nyan Syndrome
- Profound neuro-disability
- Exaggerated or abnormal oral reflex, habit, pain and/or frustration
Why does drooling occur in people with LD?
- Abnormalities in swallowing rather than absence of swallowing
- Difficulty moving saliva to back of throat
- Poor mouth closure
- Jaw instability
- Tongue thrusting
How to treat drooling?
- Multidisciplinary team make individual assessment
- Technqiues to improve posture
- Treatment with nonpharmacologucal and non-surgical methods
- Careful monitoring for oral complications
How can bruxism and NCTSL be treated?
- Splints if compliant
- Opinion sought from dental specialist
What is erosion advice?
- Fluoride mouthwash for swallowing difficulties
- Toothpaste that is low in abrasion, low acidity, high-fluoride and antihypersensitivity
- Brushing delayed an hour after drink or food
- Fluoride varnish
- Referral
- Chew sugar free gum
How is dry mouth treated?
- Saliva replacements may be helpful
- The use of sugar-free chewing gum and sugarfree fluids is advised ( if possible?)
- The mouth should be examined regularly
- Fluoride rinses ( if possible?) or high fluoride
containing toothpastes are advised - Referral to an appropriate dental specialist
may be required
How are feeding problems overcome?
- Individual assessment
- Good OH promoted
- Low foaming toothpaste (proenamel)
- Use of suction toothpaste
- Therapy to reduce oral defensiveness
How are thickeners useful?
- Useful for dysphagia
- Thickening to prevent aspiration
What are the options for LA?
- Behavioural management
- Conscious sedation
- GA
What are the aims of conscious sedation?
- Reduce fear and anxiety
- Augmenting pain control
- Minimise movement and increase safety
When is GA utilised?
- Majority Intellectual Impairment
- Multiple Disabilities
- Dental anxiety /Phobia
- Medical reasons – control
- Behavioural- uncooperative to allow for
What is the risk of GA?
- Death 1 in 100,000 to 1 in 200,000
- Increases with age, complex of surgery, emergency surgery
- Brain damage, nausea and vomiting, lethargy
- Increased complexity with increasing co-morbidity
- Confusion and memory loss
- Dizziness
- Sore throat
- Allergic reaction to anaesthetic
What are the dental features of people with Down Syndrome?
- Delayed eruption of teeth
- Crowded or misaligned teeth
- Poor oral hygiene
- Microdontia
- Class III malocclusion
- Narrow upper arch and palate
- Flat facial profile
- Small maxilla
