SYMPOSIUM: SPECIAL EDUCATIONAL NEEDS AND DISABILITY
Dental health for children
with special educational
needs and disability
Annabelle Carter
Lisa Clarke
Claire Stevens
Abstract
There are 1.37 million children and young people (CYP) with special
educational needs and disability (SEND) in the UK. These CYP have
more complex needs and may require more expertise, support and
reasonable adjustments in the dental setting. There are high levels
of unmet dental need for this cohort of CYP. Unmanaged dental dis-
ease, such as dental caries, can impact on a child’s quality of life
and wellbeing. All healthcare professionals who have contact with
CYP with SEND have an important role to play in trying to improve
the oral health of their patients. This can be achieved by educating
parents, carers and patients, delivering consistent and supportive
dental preventative messages, and where required, liaising with, or
signposting to dental professionals. This paper outlines oral conditions
that CYP with SEND experience, how they are managed by the dental
team, reasonable adjustments, and evidence-based guidelines that
should be followed to help prevent and treat oral disease.
Keywords Dental caries; dental decay; dental health; fluoride; oral
health; oral health promotion; prevention; special educational needs;
toothbrushing
What are special educational needs and disability (SEND)?
Special education needs and disability is a term used for CYP
who have conditions which affect numerous functions and the
ability to learn. Their behaviour, ability to understand, commu-
nicate, interact with others, and physical/sensory ability can be
affected, with difficulties ranging in severity. The number of
pupils with SEND in the UK was 1.37 million in 2020, according
to the Department of Education.1
SEND encompasses a wide range of conditions, including
autism spectrum disorder (ASD), visual or hearing impairments,
Annabelle Carter BChD MFDS RCSEd MPaedDent, Specialist in Paediatric
Dentistry, Leeds Dental Institute, Leeds, UK. Conflicts of interest:
none declared.
Lisa Clarke BDS (Hons) MFDS RCSEd, Specialty Dentist in Paediatric
Dentistry, Department of Child Dental Health, University Dental
Hospital of Manchester, Manchester, UK. Conflicts of interest: none
declared.
Claire Stevens BDS (Bristol) MFDS RCSEd MPaed Dent RCPS MPhil FDS (Paed
Dent) RCSEd, Consultant in Paediatric Dentistry and Honorary Clinical
Professor, MAHSC, Department of Child Dental Health, University
Dental Hospital of Manchester, Manchester, UK. Conflicts of interest:
none declared.
PAEDIATRICS AND CHILD HEALTH 32:8
neurodevelopmental disorders, attention deficit hyperactivity
disorder (ADHD), anxiety and some inherited conditions such as
Down syndrome. These CYP often have multiple and/or complex
health and educational needs with inter-disciplinary health care
required.
Why is dental health important?
The NHS Long Term Plan pledged that CYP with learning dis-
abilities have their needs met by eyesight, hearing and dental
services as part of general screening services which should be
easily accessible.2 This was part of a vision to ensure that all CYP
with SEND can live happier, healthier lives, recognizing that
access to dental care should be a priority.
Oral healthcare teams play a vital role in overseeing the de-
livery of preventative dental advice such as toothbrushing in-
structions and diet advice to help prevent development of dental
disease, screening for oral disease, and where necessary, man-
aging oral disease. Untreated oral disease such as tooth decay can
impact on a child’s life or general health leading to pain, diffi-
culty eating, sleepless nights, and necessitating time off school.
Such disease can lead to localized infection such as abscesses, or
in more severe cases, systemic infection requiring hospitalisation
which can be life-threatening. This highlights the importance of
CYP having access to regular dental care to support prevention
and early diagnosis.
CYP with SEND are known to have more oral health issues
compared to that of the general child population due to the medical
condition itself, or the effect of managing it. They can also have
higher levels of unmet dental need such as untreated tooth decay.
Their medical condition can make these CYP more prone to dental
disease, which can be more difficult to manage in the dental setting
due to factors such as cooperative ability or anxiety. This highlights
the stark health inequalities that these CYP suffer.
Importantly, oral health can have a range of implications on
general health. The most common cause of premature death for
CYP with learning disability is chest infections, such as aspiration
pneumonia. To help improve respiratory outcomes for these CYP,
management of risk factors for developing pneumonia should be
prioritized. One of the biggest risk factors for aspiration pneu-
monia is poor oral hygiene and being dependent on carers for
mouth care. Dental caries and gum disease will increase the vol-
ume of pathogenic bacteria in oral secretions and increase the risk
of aspiration, thus it is important that dental health is prioritized.
Challenges with access to dental care
There is currently a crisis with access to dentistry due to numerous
factors including workforce shortages, meaning large swathes of
the population are not able to attend an NHS dentist or experience
lengthy delays accessing care. This problem is compounded for
SEND CYP who often need specialised care and reasonable ad-
justments, which make dental care more challenging and time
consuming to provide. Additional time to treat such CYP is not
recognized in the current dental payment banding system for NHS
primary care.
Parents and carers report finding the system difficult to navigate
with many seeing multiple providers before they find a team with
expertise to treat their child. Many dentists lack confidence inter-
acting with and treating SEND CYP and are unwilling to treat them,
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 SYMPOSIUM: SPECIAL EDUCATIONAL NEEDS AND DISABILITY
due to a perceived or real lack of knowledge, expertise, enhanced
skills or time which are often required. The problem is exacerbated
by the complex referral systems used to access specialist dental
systems which vary greatly depending on geographical location.
This often means that such CYP are not regularly seen by a dentist,
are unable to find a dentist, or are referred from primary general
dental practitioners to community dental services and are subject to
a “postcode lottery” in access to care.
There is often significant parent/carer anxiety surrounding
dental visits such as the ability of the child to cope in an unfa-
miliar environment and parental fear of the dentist. These atti-
tudes may act as a barrier for parents/carers seeking dental care,
as dental visits can be a stressful experience for families. In
addition, travelling to dental appointments is reported as being
difficult. As well as this dental health is often low on a long list of
competing priorities, so there can be delays in receiving neces-
sary dental care such as examinations or prevention.
Delays are not without consequence. Oral health can deteri-
orate whilst waiting to be seen, where a once manageable oral
condition is no longer manageable by simple measures and re-
quires extensive treatment, which is more challenging to deliver.
This, amongst other reasons such as ability of the child to cope
with dental treatment is often why there are higher levels of
untreated dental disease and toothless-ness in SEND CYP.
It is important to consider that parents may themselves have a
disability, learning difficulty or lack ability to understand
important messages given by health care professionals. This may
be an additional barrier for CYP receiving oral care at home, or
attending the dentist.
Oral health of SEND CYP: how is the oral environment
affected?
Tooth decay
There is mixed evidence about whether CYP with SEND have
higher or lower levels of dental decay (known as caries) than those
without SEND, but they are no more susceptible to dental decay
than any other child. Caries can be associated with the following
risk factors; frequent vomiting, gastro-oesophageal reflux, reduced
saliva flow, sugar-containing medications, high or frequent dietary
sugar intake such as snacking, poor oral hygiene with infrequent or
limited brushing, and limited fluoride toothpaste use.
Some medications, such as Ritalin used for ADHD has a side
effect of xerostomia (reduced saliva and dry mouth) which can
increase decay risk. CYP motor function impairment and poor
muscle coordination means children can retain food in their
mouths, known as “pouching”, rather than swallowing. This
habit can lead to increased susceptibility to caries.
There is strong evidence that if CYP with SEND have tooth
decay, the decay is more likely to either be untreated, or treated
by extracting the tooth rather than restoring it. In young CYP
where the primary tooth is extracted, this can cause space loss,
which leads to issues with dental crowding and brushing in the
future.
Gum disease
The early stages of periodontal (gum) disease is known as
gingivitis, which occurs when soft deposits of plaque containing
bacteria build up, and is reversible. Signs of gingivitis are red
PAEDIATRICS AND CHILD HEALTH 32:8
swollen gums that bleed easily, particularly on brushing. If soft
plaque deposits aren’t removed, it can mineralise into hard cal-
culus which cannot be removed with toothbrushing alone and
needs professional debridement. Periodontitis is more severe
gum disease, causing irreversible destruction of the supporting
tissues which can lead to bone loss, tooth mobility and eventual
tooth loss. Periodontal disease is more common in SEND CYP if
they have poor oral hygiene, thus a focus on good tooth-brushing
to optimise oral hygiene is key. Early onset, rapidly progressing
periodontal disease is much higher in CYP with Down syndrome,
or those with an impaired immune system or connective tissue
disorder, which can lead to tooth loss.
Gum overgrowth (i.e. gingival hyperplasia) can occur due to
side effects of certain medications. These medications include
anticonvulsants such as phenytoin which can be prescribed in
such CYP. Other drugs known to cause gingival hyperplasia but
are less frequently prescribed for SEND CYP are calcium channel
blockers such as nifedipine and immune-suppressants such as
cyclosporine. This gingival hyperplasia can impede tooth erup-
tion, impair function such as speaking and chewing, impact on
the child’s physical appearance and impact the ability to brush
the teeth and gums thoroughly which further aggravates the
condition.
Oral habits
CYP with SEND can be prone to damaging oral habits, such as
picking gums, which can damage the supporting periodontal tis-
sues and cause painful oral ulceration. Other damaging oral habits
may be present, including: bruxism, which is the persistent
clenching and grinding of teeth which can lead to extensive tooth
wear, mouth breathing which can dry gingival tissues and exac-
erbate gum disease, tongue thrusting, and other self-injurious
behaviour such as lip biting, and pica where non-food items are
ingested. There can be numerous reasons for these including
hyposensitivity. In some reports, CYP with ASD can exhibit more
extreme self-injurious behaviour such as extracting their own
teeth.
Dento-alveolar trauma
CYP with SEND have increased risk and incidence of dental and
oral trauma, particularly those with intellectual disability, coor-
dination or mobility issues, ASD, ADHD, seizures and visual
impairments. The consequences of dental trauma can require
extensive dental treatment spanning many years. CYP with dis-
abilities are at higher risk of abuse and/or neglect.3 This could
present as oral/dental/facial injuries which health professionals
may miss as they mistake them as part of the child’s condition.
The need to raise awareness and ensure adequate education of
safeguarding practices is important for all health professionals.
Dental anomalies
The age at which teeth erupt into the mouth may be delayed or
accelerated. CYP with Down syndrome often have delayed tooth
eruption. Anomalies in tooth shape, size and number can also be
present. CYP with SEND are more likely to have malocclusion,
i.e. anomalies in which the upper and lower teeth bite together.
This can be due to muscular abnormalities, delayed tooth erup-
tion and tongue thrusting. Crowding is often encountered. Often,
orthodontic treatment with braces may not be a feasible option
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 SYMPOSIUM: SPECIAL EDUCATIONAL NEEDS AND DISABILITY

for many due to factors such as cooperation and concerns with
maintaining optimal oral hygiene.
Defects in the outer tooth structure called enamel hypoplasia
are more common in CYP with SEND including those with visual
impairment and cerebral palsy. This can make teeth very sensi-
tive, weaker to biting forces, more prone to decay, or have pits,
lines or discoloured patches.
Tooth wear
Tooth wear can be high in CYP with SEND, particularly cerebral
palsy, intellectual disability, due to frequent tooth grinding
coupled with gastro-oesophageal reflux disease where reflux of
acidic stomach contents can erode and soften the tooth tissue.
Oral hygiene
CYP with SEND (e.g. visually impaired, ADHD, cerebral palsy,
ASD) are known to have poorer oral hygiene, and there are
significant challenges undertaking daily oral care due to factors
such as: reliance on a third party, poor training of parents/carers
in oral care, parental fear that brushing is traumatic or painful for
the child, limited mobility and manual dexterity, oral aversion,
clenching/biting on brush, and difficulty accepting oral stimu-
lation due to hyper-sensitivity. Collaboration between speech
and language therapists and dental professionals to try to
desensitise CYP who won’t tolerate brushing to help allow home
brushing would be ideal however scarce time and resources have
made this difficult to fulfil.
dental environment and changes in processes to support pa-
tients.4 On an individual basis, tailored support for each patient
is required to facilitate dental care, according to the child’s needs.
Preparation for dental visits is essential to reduce anxieties
and the fear of the unknown. Pre-appointment questionnaires
can be sent out to gain an insight into the patient’s likes/dislikes,
communication aids, and questions asking for any further in-
formation which the parent/carer may feel beneficial. Further-
more, a child-friendly leaflet or social story of what to expect at
the appointment can be sent in advance to help preparation
(Figure 1). It may also be beneficial to have a desensitising visit
for the child to greet the team, and explore the environment.
Appointment times often require extending to ensure adequate
time is allocated to the child; in addition, the parents/carers
should be involved in organising the best appointment time in
the day based on the child’s individual needs.
For those with sensory needs such as photophobia, questions
about light sensitivity and appropriate dark tinted glasses should
be provided. Establishing how the child communicates is vital
and whether any communication aids are used such as Makaton
symbols (Figure 2). If the child lip reads, ensuring that the mouth
is visible and that words are spoken slowly is a challenge with
the face masks required at the dentist. Sign language support
may also be required.

Unmet dental need

There are much higher levels of unmet dental need in CYP with
SEND, compared to that of the general population. This can be
for a variety of reasons including access, lack of specialised care,
and long waiting lists for the appropriate care. The high levels of
untreated dental disease can often mean the child suffers un-
necessary pain, and infection. It also means the disease extent is
worse before treatment is sought, often with infection present. As
such, they are more likely to have recurrent courses of antibiotics
prescribed, as well as dentists being unable to treat the cause of
the infection in the dental chair due to cooperation issues.

Challenges and reasonable adjustments in delivering

dental care to SEND CYP
In addition to the increase in oral health problems, there are
multiple challenges to delivering dental care for SEND CYP. This
cohort of CYP may not have the ability to recognise, localise or
communicate if they are having dental symptoms such as dental
pain, which can lead to changes in behaviour patterns. This may
be mistakenly attributed to the child’s disability and may not be
properly investigated. Patients, particularly those with ASD may
be hypersensitive to specific sights, sounds and touch and thus
may not tolerate dental treatment. Unfortunately for many SEND
patients the only feasible option due to limited communication
and co-operation is treatment under general anaesthetic. Care
pathways and waiting lists for dental general anaesthetics are
very long, and vary depending on geographical location.
There is a legal obligation for dental services to make
reasonable adjustments to ensure that their patients with
learning disabilities can use their service in the same way as Figure 1 A patient journey booklet for children attending a dental
other people. This involves both practical adjustments to the hospital. Reproduced with permission.

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 SYMPOSIUM: SPECIAL EDUCATIONAL NEEDS AND DISABILITY

Figure 2 Makaton signs and symbols related to dentistry. Reproduced with permission from the Makaton Charity.

Some CYP may be averse to certain flavours and textures
which may pose a challenge not only to completing dental
treatment, but also to toothbrushing. OraNurse is a specially
formulated fluoride toothpaste which is flavour free and non-
foaming which is helpful to those sensitive to strong flavours.
There are also other toothbrushing aids such as three-sided head
toothbrushes and foam bite props which can be used (Figure 3).
These can be helpful for children and young people who won’t
cooperate or who lack motor control to keep their mouth open.
They are made from special foam with a rigid core to add sta-
bility. This is sturdy enough to resist biting pressure, but has
enough “give” to be comfortable for the person receiving care.
For those with mobility problems the dental surgery needs to
have adequate space and access. Some patients can transfer from
a wheelchair into the dental chair, others require specialist
hoists, other patients can be assessed or treated in their

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 SYMPOSIUM: SPECIAL EDUCATIONAL NEEDS AND DISABILITY
Figure 3 (a) OraNurse unflavoured toothpaste and (b) foam bite prop.
Reproduced with permission from RIS Products.
wheelchairs as some can recline or are specially moulded and
others require specialized wheelchair tippers. Certain specialist
equipment like hoists and tippers are only available at certain
specialist community dental clinics which require referral, not
general dental practitioners in primary care.
There should always be a strong emphasis on prevention of
dental diseases with preventative advice given to the patient and
their carer and treatments such as the application of fluoride
varnish if possible. Recall times should also be short and oral
health messages need to be reinforced at each visit. For some
patients with SEND some simple treatments may be completed in
PAEDIATRICS AND CHILD HEALTH 32:8
the dental chair, and local anaesthetic or inhalation sedation with
nitrous oxide may be suitable for some, if co-operation and un-
derstanding allows. Treatment under general anaesthetic how-
ever is commonly required and this should be comprehensive in
nature. Separate cubicles on the ward, engagement of all team
members and involvement of hospital play therapy teams to
support the admission are very helpful.
What can healthcare professionals (HCPs) do?
A collaborative approach between HCPs is needed for holistic
care of patients with SEND. Key messages of prevention of oral
disease should be reinforced and appropriate signposting and
referral to dental service is required.
HCPs should recommend CYP are taken to their dentist for an
examination as soon as their first tooth erupts, usually around
the age of 6 months. All children should have had their first
dental visit by the age of one. Even if a child does not allow a full
examination, this visit gives the child a valuable opportunity to
acclimatise to the dental setting and ensures preventive advice is
discussed with the family.
Dental Check by One (DCby1) is a nationwide campaign led by
The British Society of Paediatric Dentistry (BSPD) in partnership
with the office of the Chief Dental Officer of England. DCby1 is an
essential part of the Starting Well Programme, aiming to reduce
oral health inequalities and improve oral health in CYP.
CYP with SEND will likely have multiple HCPs looking after
them at any one time; unfortunately dental health is often low on
parents/carers priority list. With this in mind it is key for HCPs to
ask if such CYP see a dentist to help parents/carers understand
its importance, and ensure dental needs are being met.
Advice for health care professionals working in the UK
An awareness of the structure of dental services is beneficial to
facilitate appropriate signposting and/or referral by HCPs. Dental
services in the UK fall under the following categories:
1) General Dental Services e Can be directly accessed by the
public and are ‘high street dental services’.
2) Community Dental Services e These services provide treatment
for patients who may have difficulty accessing high street dental
services due to their social, medical or dental need. They are
often the most appropriate service for SEND patients and both
medical and dental professionals can refer patients. Admission
criteria and services may vary depending on the region.
3) Hospital Dental Services e These are highly specialised dental
services. Patients are seen on referral from medical or dental
professionals for specialist advice and or treatment.
Healthcare professionals can help CYP with SEND access
dental treatment by raising awareness of the importance of
dental assessment with the child’s parent/carer in the first
instance. Patients requiring a general NHS dentist should be
directed to the NHS website ‘Find a dentist’ page. Referral forms
for community dental services will vary between locations can
also be completed by HCPs. If you require further advice on the
where to refer a child with SEND please contact the chair of your
local paediatric dentistry Managed Clinical Network (MCN).
Dental care is also important for CYP who are inpatients in
hospital and especially those with additional needs. Mini
Mouthcare Matters (Mini MCM) is an initiative funded by Health
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 SYMPOSIUM: SPECIAL EDUCATIONAL NEEDS AND DISABILITY

Education England which aims to empower medical pro-
fessionals to take ownership of oral health care. It encourages all
nursing, medical and HCPs to ‘lift the lip’ and identify common
oral health conditions. It also aims to include oral health care as
part of the general health care needs. Mini MCM was originally
established to support the oral care of any paediatric in-patient
with a hospital stay of over 24 hours. Mini MCM has been very
successful and should be described as the umbrella term for any
time a non-dental HCP is engaged with children’s oral health.
Learning has been translated to a wide variety of settings
including hospices, secure settings and special educational set-
tings. A wide range of training and resources are available from
the e-learning for health website, including screening tools,
mouth care plans and posters (Figure 4).
Further dental advice for hospital patients can be sought from
hospital dental teams or community dental teams which have
links to the hospital. A collaborative approach is always benefi-
cial if the child requires a general anaesthetic and the option of a
joint procedure between dental and medical specialities should
be explored, if possible and appropriate, to reduce multiple an-
aesthetics with their associated morbidity and risks.
It is best practice for CYP with an impairment or disability to
have a bespoke and comprehensive oral health plan incorporated
within their overall health plan. This plan should be written by

Figure 4 Resource poster from the Mini Mouthcare Matters initiative. Reproduced under the Open
Government Licence.

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 SYMPOSIUM: SPECIAL EDUCATIONAL NEEDS AND DISABILITY
the multi-disciplinary team involving dental professionals and
disseminated to all involved in the child’s care.
Finally, oral health promotion and prevention is essential and
parents/carers should be directed to resources available to sup-
port their child (see recommended reading). An awareness by
HCPs of such resources and the sharing of knowledge through
appropriate education to parents can support and motivate
families to understand the importance of oral health.
Conclusion
SEND CYP often face multiple challenges with attaining optimal
oral health, which can have serious implications on general health
and quality of life. Accessing appropriate and regular dental care
can be a challenge for families of SEND CYP, thus is it vital that
health care professionals adopt a collaborative approach to help
facilitate this and have consistent messages about the importance
of oral health, regular at-home oral care, and visiting the dentist.
If possible, awareness of general principles of oral health pre-
ventative advice, and oral health promotion or signposting to re-
sources available to support their child is advised. Furthermore,
health care professionals should familiarise themselves with the
local referral pathways for SEND CYP requiring dental care. A
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PAEDIATRICS AND CHILD HEALTH 32:8
FURTHER READING
A Parents’ Guide to oral health and dental care for children with a
learning disability, autism or both [Internet]. 2021.Seeability.org.
Available from: https://www.seeability.org/sites/default/files/2021-
05/contact_aparentsguide_web_single.pdf.
British Society of Disability and Oral Health. Clinical guidelines and
integrated care pathways for the oral health care of people with
learning disabilities [Internet]. 2012. Bsdh.org. Available from:
http://www.bsdh.org/documents/pBSDH_Clinical_Guidelines_
PwaLD_2012.pdf.
BSPD. Advice. For parents of children with autism [Internet]. 2017.
Available from: https://www.bspd.co.uk/Portals/0/BSPD%
20Advice%20for%20parents%20of%20children%20with%
20autism%20Jan%2017.pdf.
Department of Health and Social Care. Delivering better oral health: an
evidence-based toolkit for prevention [Internet]. 2014. GOV.UK.
Available from: https://www.gov.uk/government/publications/
delivering-better-oral-health-an-evidence-based-toolkit-for-
prevention.
Devalia U, Tomlinson S, Lau K, Bolooki H, King OJ, Liu C. Mini mouth
care matters [Internet]. 2019. Nhs.uk. Available from: http://
mouthcarematters.hee.nhs.uk/wp-content/uploads/sites/6/2020/
01/MINI-MCM-GUIDE-2019-final.pdf.
National Autistic Society. Going to the Dentist. [Internet]. 2019.
Available from: https://www.autism.org.uk/advice-and-guidance/
topics/physical-health/going-to-the-dentist/parents.
Practice points
C Children with SEND are at increased risk from the conse-
quences of poor dental care.
C Many families require encouragement to ensure that their
child’s dental care is considered a priority and they may
require support in overcoming practical barriers that reduce
access to care.
C All children should have visited the dentist by the age of 1
year for a dental check.
C Adjuncts which can help to assist the provision of care at
home include the use of specialist toothpastes, tooth-
brushes and foam dental blocks.
296 Ó 2022 Elsevier Ltd. All rights reserved.