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ARTICLE

ABSTRACT Oral health of patients with intellectual

A systematic review of original studies
was conducted to determine if differ-
ences in oral health exist between
adults who have intellectual disabilities
(ID) and the general population.
Electronic searching identified 27
studies that met the inclusion criteria.
These studies were assessed for
strength of evidence.
People with ID have poorer oral
hygiene and higher prevalence and
greater severity of periodontal disease.
Caries rates in people with ID are the
same as or lower than the general popu-
lation. However, the rates of untreated
caries are consistently higher in people
with ID. Two subgroups at especially
high risk for oral health problems are
people with Down syndrome and
people unable to cooperate for routine
dental care.
Evidence supports the need to
develop strategies to increase patient
acceptance for routine care, additional
training for dentists to provide this care,
and the development of more effective
preventive strategies to minimize the
need for this care.
disabilities: A systematic review
Patrick L. Anders, DDS, MPH;1* Elaine L. Davis, PhD2
1Assistant Professor; 2Professor, Department of Oral Diagnostic Sciences, State University of New York
at Buffalo School of Dental Medicine Buffalo, New York.
*Corresponding author e-mail: planders@buffalo.edu
Spec Care Dentist 30(3): 110-117, 2010
Introduction
Poor oral health can lead to pain, difficulty eating, sleep disturbance, and decreased
self-esteem, all of which can have a dramatic impact on an individual’s quality of life.1
Dental caries and periodontal disease are among the most common secondary condi-
tions affecting people with intellectual disabilities (ID).2 The oral health needs of
individuals with ID are complex, and may be related to underlying congenital or devel-
opmental anomalies as well as inability to receive adequate personal and professional
care to maintain oral health.3 Research suggests that people with ID such as mental
retardation (MR), are more likely to have poor oral hygiene and periodontal disease
and possibly more likely to have caries than people without ID.1,3 Many studies have
examined the oral health of various groups of individuals with ID including children,4-7
institutionalized people,8-11 and specific ethnic groups.12-15 Recent studies have exam-
ined the oral health of other convenience samples such as groups of athletes
participating in the Special Olympics.16-18

KEY WORDS: oral health, special

care, systematic review Much of the research has compared
different groups of individuals with ID,
often with no control or reference group.
To date, no national studies have been
conducted to determine the prevalence of
oral diseases among populations with
disabilities,3 making it difficult to deter-
mine if the oral health of adults with ID
differs from that of the general popula-
tion. Such a comprehensive comparison
would help establish whether disparities
exist and could be a step toward develop-
ing strategies to address the disparities if
any were found.
The objective of this review was to
examine the available literature concern-
ing the oral health of adults with ID to
determine if differences in oral health
status exist between those who have ID
and the general population.
Methods
Search strategy
Electronic searching was performed
using the following data bases: MED-
LINE (1975–2008), PubMed Clinical
Queries, and PsychLIT. The search terms
used were related to the patients of inter-
est—dental care for the disabled, mental
retardation, and Down syndrome; the
oral condition—caries, periodontal dis-
ease, mouth diseases, tooth disease; and
the type of study—comparative study,
randomized controlled trial, meta analysis
or review. The search was limited to
English language literature from 1975
to October 2008, as studies conducted
prior to 1975 predate the adoption of the
Developmentally Disabled Assistance and

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O R A L H E A LT H O F PAT I E N T S W I T H D I S A B I L I T I E S
Bill of Rights Act,19 and are not reflective
of the current status of the population
with ID. Nine hundred and eighty-four
articles were initially identified. A review
of abstracts based on the criteria below
led to initial consideration of 86 articles.
Further review of full texts resulted in
inclusion of 26 articles. Peer review
resulted in the addition of one article for
a total of 27.
Studies were included if they met the
following three criteria:
1. Adult human subjects with mental
retardation or a similar ID.
2. At least one quantitative measure of
oral health status.
3. Comparison of subjects to a control
or comparison group without ID.
Assessing the strength of included
studies:
Systematic reviews generally assess
the methodological quality of included
studies.20 Quality in this context refers to
internal validity, or the minimization of
bias.21 One goal of a review is to assess
the overall strength of the scientific evi-
dence, with more weight given to studies
that were free of bias. To prevent selec-
tion bias, the comparison groups should
be as similar as possible except for the
factors under study.20 Since the use of
matched controls generally allows for
direct comparisons and provides stronger
evidence than the use of population sta-
tistics, studies that utilized control
groups selected for the specific study and
matched by age and gender received
higher quality scores. Studies that uti-
lized a comparison group derived from
available preexisting statistics were
assigned a lower score. Our instrument
for assessing quality was developed
specifically for this review, based on the
Newcastle-Ottawa Scale (NOS) for
assessing the quality of nonrandomized
studies.22 The NOS judges a study on
three broad areas: the selection of study
groups, comparability of these groups,
and ascertainment of either exposure or
outcome, depending on the type of study.
Quality scores are assigned according to
whether or not a study meets certain
parameters within these areas. For our
Anders et al.
study, the major areas were defined as
inclusion criteria: study group includes
adults with ID (selection); comparison or
control group (comparability); and quan-
titative measure of oral health
(outcome). Only studies that satisfied all
three criteria were included in the review.
Additional quality points were awarded
for specific parameters within these crite-
ria. The result was an instrument with a
total of 10 quality points, with a mini-
mum score for inclusion being 3 (1 for
each inclusion criterion) and additional
points being awarded for certain specific
parameters. The instrument is presented
in appendix A. All papers were evaluated
independently by two reviewers, to
determine if minimum inclusion criteria
were met and if so, to assign a score.
When a discrepancy between scores
existed, discussion led to a consensus
score in all cases.
Results
Twenty-seven studies were included in the
review, and are summarized in Table 1. Of
these, eight employed a design utilizing
controls selected specifically for the study.
The remaining studies used existing data
derived from larger studies of the general
population.
With two exceptions, these studies
found that people with ID have
poorer oral hygiene than the general
population.13,14,23-34 Two studies found
no significant difference in hygiene
levels.35,36 No studies demonstrated or
suggested better hygiene in individuals
with ID. Oral hygiene level was correlated
with many factors including age,37 type
of caregiver,33 and physical disability.34
The evidence also strongly supports
that people with ID have a higher preva-
lence and greater severity of periodontal
disease than the general population. This
has been demonstrated in people with
Down syndrome (DS),15,27,32,35-38 non-DS-
related MR,16,23,24,26,38,39 and other forms
of developmental disability (DD), includ-
ing autism.5 No study found a lower
prevalence or lower level of severity of
periodontal disease in people with ID.
In contrast, most studies that exam-
ined caries rates concluded that these
rates in people with ID were either the
same as the general population,14,30,36,40
or lower.5,12,24,38,41,42 Only one study
found a higher caries prevalence in
adults with ID.43
While the levels of caries were not
found to be higher, the levels of
untreated caries were consistently higher
in people with ID. Several studies
showed more missing and decayed teeth,
but fewer filled teeth in individuals with
ID.12,23,30,31,33,34,40
Discussion
The U.S. Department of Health and
Human Services Agency for Healthcare
Research and Quality has recommended
evaluating the strength of evidence in
three domains: quality, quantity, and con-
sistency.20 Quality is the aggregate of
quality ratings for individual studies,
predicated on the extent to which bias
was minimized.20 This review found wide
variation in the quality of studies. The
possible range of quality scores was from
3 (minimally meets inclusion criteria) to
10 (meets all quality criteria). The
included studies received scores from 3
to 9. The average score was 5.7, indicat-
ing moderate overall quality if the range
was divided equally into low (3.0–5.33),
moderate (5.34–7.66), and high
(7.67–10.0) quality according to the
instrument used.
Quantity of evidence is the magni-
tude of effect, number of studies, and
sample size or power.20 It was difficult to
assess the magnitude of effect for these
studies because of a lack of uniform
reporting of findings. Twenty-seven stud-
ies were included and sample size ranged
from 17 to 9,620. All studies reported
significant findings, providing evidence
of adequate power.
Consistency is the extent to which
similar findings are reported using simi-
lar and different study designs.20
Consistency of evidence in this review
was high, with similar findings from
studies of various size and design, from
12 countries, with subjects in the com-
munity and in various living
arrangements, and with several defini-
tions of disability.
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Table 1. Included studies and summary of findings.

Author Controls/
Date Score Subjects Measures Findings
(country) comparison group
Hinchliffe 1988 9 324 adults with mental 165 age and DMFT, oral cleanliness, People with MR had poor oral hygiene,
(England) retardation (MR) gender-matched gingivitis, periodontal similar caries prevalence, more
controls status, dentures untreated caries, more gingivitis, more
perio disease, worse OH, more eden-
tulism, more traumatized teeth.
Sakellari 2005 8 70 adolescents and 70 people with Probing depth, probing People with DS had worse oral hygiene,
(Greece) young adults with Down cerebral palsy, 121 attachment level, bleeding more BOP, more severe periodontal
syndrome (DS) age-matched con- on probing (BOP), hygiene, destruction, earlier, heavier colonization
trols microbiology with periodontal pathogens.
Zigmond 2006 7 30 adults with DS 28 age-matched Plaque scores, BOP, prob- People with DS had similar oral hygiene
(Israel) healthy controls ing depth, gingival and gingival measures but severe peri-
recession, clinical attach- odontal disease. Prevalence, extent,
ment level, radiographic and severity of periodontitis was signifi-
bone loss cantly greater in DS group.
Cheng 2007 7 65 adults with DS, age 65 age and gender- DFT, plaque index (PI), People with DS had more plaque, fewer
(China) 17–42 matched controls BOP, pocket depths remaining teeth, more dental anomalies,
fewer caries but more BOP, more
severe periodontal disease, fewer filled
teeth, more retained primary teeth.

Lopez-Perez 2002 7 32 people with DS, age 32 age and gender- Simplified oral hygiene DS group had more severe gingivitis
(Mexico) 15–39 matched controls index (SOHI), gingival but not periodontitis; greater extent of
index (GI) attachment gingivitis and periodontitis, lower levels
levels of calculus, similar plaque levels.
Shapira 1991 7 12 institutionalized 11 healthy and 12 DMFT, community peri- Periodontal treatment needs of DS and
(Israel) people with DS, age non-DS-institution- odontal index of treatment non-DS MR groups were higher than
20–48. alized MR age and needs (CPITN) that of healthy controls. DS group had
gender- matched lowest caries experience. No correla-
controls. tion between salivary pH and caries
levels found.
Seirawan 2008 6 102 institutionalized and NHANES survey of DMFT, PI, TMD, intraoral Study group had higher caries preva-
(USA) noninstitutionalized general population anomalies lence than general population, poor oral
adults with developmen- hygiene, and higher DMF.
tal disabilities (DD)
Oredugba 2007 6 43 children and young 43 age and gender- SOHI, DMFT Angle’s clas- DS group had poorer oral hygiene, no
(Nigeria) adults with DS matched controls sification of malocclusion significant difference in caries preva-
lence, more malocclusion, more
treatment needs.
Donnell 2002 6 265 people with disabili- Hong Kong adults DMFT, PI Sample had poor oral hygiene, increas-
(China) ties, age 25–35 in general popula- ing with age. Sample had high number
tion of missing teeth but lower DMFT than
general population.
Cumella 2000 6 50 adults with intellec- UK adult dental DMFT, oral hygiene, trau- Level of oral health depended on care-
(England) tual disabilities (ID) survey of general matized teeth, general oral giver. Sample had poorer oral hygiene,
population condition more decayed and missing but fewer
filled teeth, and high percentage of
traumatized teeth.

Scott 1998 6 101 adults with DD, age Age-matched com- DMFT, BOP, pocket People with DD had more severe peri-
(Australia) 21–53 parison group from depths, calculus, mucosal odontal disease, more mucosal
National Oral pathology, malocclusion pathology and malocclusion but lower
Health Survey levels of calculus and lower levels of
caries.

Continued

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Table 1. Continued.
Author Controls/
Date Score Subjects Measures Findings
(country) comparison group
Kendall 1991 6 350 mentally handi- General population DMFT, PI, calculus and Study group had poor oral hygiene,
(England) capped adults of adults in UK gingivitis, WHO denture extensive gingivitis, and high calculus
criteria prevalence but lower caries prevalence
and lower rate of edentulism than com-
parison group.
Francis 1991 6 195 handicapped adults, Dental health survey DMF, dental cleanliness, Study group had worse dental cleanli-
(England) age 25–34 of general popula- calculus, periodontal ness and periodontal health. Study
tion in same region condition, malocclusion, group had fewer filled teeth and more
dentures untreated caries.
Shaw 1990 6 329 dentate mentally General adult popu- DMFT, PI, calculus, Caries prevalence was lower in study
(England) handicapped adults lation of similar age pocketing, BOP group. Oral hygiene was poor, worst for
people with physical disabilities as well
as ID. More missing than filled teeth
compared to general population.
Shapira 1989 6 17 institutionalized Pooled data of DMFS, DMFT, periodontal Adults with autism had severe periodon-
(Israel) people with autism, age healthy age-matched treatment need system tal problems, more missing teeth but
17–26 adults from three lower rates of caries.
sources
Rodriguez 2002 5 166 institutionalized Spanish national DMFT Caries prevalence of entire sample was
-Vasquez adults age 20–40 with survey lower than that of adults in a national
(Spain) mild-to-moderate DD survey. Patients with DS had less
caries, lower DMFT than other groups.
Lindemann 2001 5 325 adults with DD NHANES III and one DMFT, “overall dental Sixteen percent of subjects rated as
(USA) other study of adults health” having “good” and 78% “fair” oral
health. Subjects had higher DMFT, simi-
lar rate of edentulism. 20% required
urgent attention.
Gabre 2001 5 124 adults with ID General population DMFS, reason for tooth Longitudinal study showing majority of
(Sweden) in Sweden loss tooth loss in ID group was for periodon-
tal reasons. Study group had lower
caries incidence than general population
but more tooth loss.
Gabre 1999 5 115 adults with MR General adult popu- Tooth loss, reasons for People with MR had fewer teeth and
(Sweden) lation tooth loss more tooth loss than the general popu-
lation.

Whyman 1995 5 207 intellectually handi- New Zealand study DMFT, CPITN, SOHI, Sample had more missing and decayed
(New capped, institutionalized of oral health out- root caries index teeth but similar overall caries levels.
Zealand) adults comes Sample oral hygiene was poor, more
edentulism than general population,
more periodontal treatment needs.
Strauss 1985 5 233 disabled adults, 60% North Carolina DMFT, SOHI, Periodontal Study group had poorer oral hygiene
(USA) with MR norms from Dental index scores, more calculus and debris. Study
Manpower study group had similar DMFT but more
decayed and fewer missing teeth.

Nowak 1984 5 2,218 noninstitutional- National statistics DMFT Study group had similar caries index as
(USA) ized, handicapped for general popula- general population. Study group has more
people, age 16 or older tion missing and decayed than filled teeth.
Turner 2008 4 1,021 UK Special Adult dental health 21 or more natural teeth, Study group was more likely to be free
(Scotland) Olympians, mean age 28 survey of general absence of fillings, no from fillings and untreated decay than
population in UK obvious untreated decay general population but in older age
groups subjects were more likely to be
having missing teeth.

Continued

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Table 1. Continued.
Author Controls/
Date Score Subjects Measures Findings
(country) comparison group
Tiller 2001 4 209 adults with learning UK adult dental DMFT, PI, calculus, Sample had more missing teeth and fewer
(England) disabilities, age 18–65 health survey of denture assessment filled teeth than general population, but
general population same mean caries levels. Sample had high
plaque levels.
Feldman 1997 4 713 Special Olympians, National Baseline DMFT, pain, gingivitis, Study group had lower level of gingival
(USA) mean age 26 Data from Healthy fluorosis, malocclusion, health but also lower caries level than
People 2000 hyperplasia, trauma general population, fewer sealants. 13% of
study group required urgent oral care.
Morton 1977 4 90 mentally handicapped Females in general Caries, oral hygiene, WHO Subjects had more missing and decayed
(England) institutionalized adult adult population criteria for periodontal dis- teeth and fewer filled teeth than general
females ease, calculus, edentulism, population. Subjects had poor oral hygiene
DMF and high proportion of periodontal disease,
43% edentulous.
Reid 2003 3 9,620 Special NHANES III survey DMFT, oral pain, gingivitis, It was unclear if study group had a higher
(USA) Olympians, mean age 24 of general popula- sealants, fluorosis, oral prevalence of oral pain and untreated
tion injuries caries.

DMF(T), decayed, missing, filled teeth; DFT, decayed, filled teeth; DMFS, decayed, missing, filled surfaces; OH, oral hygiene; NHANES, National
Health and Nutrition Examination Survey; TMD, Temporomandibular disorder.

Overwhelmingly, the evidence sup-
ports the idea that people with ID have
higher plaque levels and poorer oral
hygiene than the general population.
While adults with ID are not a homoge-
neous group in terms of dental health,33
a majority of individuals with MR lack
the manual dexterity required for good
plaque removal.44 Impaired physical
coordination and cognitive skills limit
the ability to independently complete
sequential tasks such as daily tooth
brushing.45 Poor hygiene can be exacer-
bated when the natural cleansing of the
oral musculature is impaired.28 In many
cases, the oral hygiene of an individual
with ID depends on the knowledge, atti-
tude, and actions of a caregiver, but
many caregivers receive minimal training
in provision of oral care.33 Lack of proper
and consistent supervision and negative
attitudes toward dental health by the
caregiver have been cited as obstacles to
good oral health.44
Because periodontal disease has a
strong negative correlation with oral
hygiene, it is not surprising that people
with ID were also consistently shown to
have more periodontal disease. In every
case where periodontal disease was meas-
ured, people with ID, including
non-DS-related MR and autism, had
more prevalent and more severe gingivi-
tis and periodontitis. In the subgroup of
people with DS, the amount of plaque
present does not fully explain the sever-
ity of periodontal disease. Therefore,
people with DS must be considered to
have additional risk factors for periodon-
tal disease. While the mechanisms are
not yet well-defined, impaired cell-medi-
ated and humoral immunity, decreased
phagocytic and chemotactic responses,
altered actions of host and bacterial-
derived enzymes and increased amounts
of prostaglandin E2 have all been sug-
gested in the pathogenesis of periodontal
disease in people with DS.27,35,36
Since caries rates are also strongly
associated with oral hygiene, it seems
reasonable to assume that people with ID
who have poor oral hygiene would have
high rates of caries. In fact, evaluation of
the data has shown that caries rates are
lower, or at worst, the same as in the
general population. A partial explanation
may be that in many institutional and
group settings, residents receive a well-
balanced diet, with supervised intake of
refined carbohydrates.39,42,46 It has also
been suggested that caries prevalence is
low because of prior removal of carious
teeth, or prior removal of teeth for peri-
odontal reasons, especially among those
with severe MR, living in institutional
settings.1,39
These studies found that in people
with ID there is a low proportion of filled
teeth compared to carious and missing
teeth. This suggests that people with ID
receive less dental treatment than the
general population, and that when treat-
ment is rendered it is more likely to be in
the form of tooth extraction rather than
restoration of the carious teeth.
One study showed that adults in resi-
dential care had significantly more
missing teeth whereas those in the com-
munity had significantly more carious
teeth.30 In addition, those living in the
community were found to access dental
services less frequently. Taken together,
this suggests that extraction was the
treatment of choice when treatment
was given.
Inability to cooperate during dental
treatment is a major factor in tooth loss.
People unable to cooperate in dental treat-
ment situations lose more teeth than those
able to cooperate, and those who can tol-
erate simple preventive procedures in a
dental setting lose fewer teeth than those
who lack any capacity to cooperate.39

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Summar y
The evidence presented in this review
supports the need for further research in
three main areas: development of strate-
gies to increase patient acceptance of
routine periodontal and restorative
dental care, development of strategies to
ensure that dentists and hygienists are
prepared to provide this care, and devel-
opment of effective preventive strategies
to minimize the need for this care.
Increasing acceptance of care will
require highly individualized approaches
encompassing behavioral and possibly
pharmacological strategies as well as
advancements in restorative dentistry
and anesthesia. These improvements are
by definition slow and expensive.
Increasing preparedness of dentists to
provide routine care for people with ID is
necessary and has begun. A lengthy effort
to bring about changes in the preparation
of dental and dental hygiene school grad-
uates resulted in the Commission on
Dental Accreditation adopting a new
standard that graduates “must be compe-
tent in assessing the treatment needs of
patients with special needs.”47 However,
many obstacles remain including limited
number of trained practitioners to pro-
vide programmatic support and limited
availability of funding.48
The greatest opportunity to improve
oral health for people with ID lies in the
development of effective prevention.
Research in this area should focus on
strategies to encourage self-care and par-
ticularly to improve daily hygiene
procedures performed by a care giver.
Based on the evidence in the literature, a
health disparity clearly exists.
Elimination of this disparity and its
implications on quality of life should
become a public health priority.
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APPENDIX

Appendix A: Instrument used to score included studies.

Author Date Journal
I. Definition of study participant: adult with intellectual disabilities (ID)a
(a) Truly representative of average person with ID in community
(b) Randomized sample or census
II. Comparison or control groupa
(a) Drawn from same community as study group
(b) Matched controls
(c) Study controls for other factors such as smoking, dexterity
III. Measurements: quantitative measure of oral healtha
(a) Same evaluator(s) examined both groups
(b) Same measures applied to both groups
Total score
a
Each of these main criteria was required for a study to be included. Total score is a sum of all parameters found to be applicable to the study.

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