Dental Care for Children with Learning Disabilities

: A Systematic Review of Treatment Provision and a Prospective Study of the Hall Technique to Improve Treatment Delivery

Abstract

Children with learning disabilities have worse health outcomes than their contemporaries without learning disabilities, even with respect to conditions not associated with their disability. In addition, ‘positive’ links between disability, socio-economic status and dental caries mean that children with learning disabilities are at risk of carrying more than their share of the burden of dental disease in society. This is compounded by their frequent inability to tolerate invasive, conventional healthcare interventions. Additionally, there is evidence to suggest that health care providers lack the confidence and knowledge to manage this cohort appropriately and effectively.

Dental caries is the commonest chronic disease in the world, affecting over 600 million children globally. Techniques for effective interventions to manage its presentation and progression have undergone significant changes in the past 20 years, with a growing evidence base illustrating the possibility and importance of disruption of the plaque microbiome’s ecology. This biological approach to management of the disease with the Hall Technique precludes the need for rotary instruments, tooth preparation and local anaesthesia.

Whilst the efficacy of the Hall Technique for managing dental caries in carious primary molar teeth is well established and the focus of a high quality evidence base, its use in children with learning disabilities, an underserved group in healthcare, is largely unknown and not well characterised for either acceptability or effectiveness.

This dissertation looked at children with learning disabilities and dental care. A systematic review was carried out to compare dental caries rates and the care and restorative indices in children with learning disabilities and children without learning disabilities. In addition, a prospective cohort study investigated the use of the Hall Technique in children with learning disabilities requiring dental intervention for dental caries.

The systematic review examined whether children with learning disabilities had a greater burden of dental caries (measured as dmft / DMFT scores) than children with no learning disabilities. It also aimed to establish whether there were inequalities between these two cohorts in terms of the amount and type of dental care delivered. MEDLINE, Scopus, Web of Science and the reference lists of included studies were searched. Titles and abstracts were screened and data extraction carried out, in duplicate, before data from the 12 studies that met the inclusion criteria were synthesised. Although the data were too heterogeneous to carry out meta-analysis, there was an overall picture that whilst children with learning disabilities tended to have lower caries rates than their contemporaries without learning disabilities, they were less likely to receive dental care when it was indicated. Further, when they did receive dental treatment, they were more likely to be treated with dental extractions than restorative interventions – a contrast to the pattern of care provided to children without learning disabilities. In addition, there was ineffective dissemination of the literature around dental care of children with learning disabilities.

A prospective cohort study (in three UK centres; Dundee, Glasgow and Sheffield) was carried out over 10 years to determine whether primary molars treated with the Hall Technique had similar failure rates in children with learning disabilities compared to children without learning disabilities. The acceptability of this intervention to the children and perceptions of treatment success in the opinion of the treating clinician, child and parent/guardian were also measured. Individual carious primary molar teeth (n=27 teeth in 16 children with learning disabilities; n=204 teeth in 162 children without learning disabilities) were followed for variable lengths of time (between six and 88 months) from crown placement with follow-up data collected at 6 monthly intervals. Sixteen children with learning disabilities, all of whom could not tolerate conventional interventionist dental treatment, received Hall crowns for 27 teeth, treated and followed up to seven years. The incidence of failure (pain and / or infection) was 3%; a success rate of 97%. The Hall Technique was considered acceptable in 81% (n=22/27) of crowns placed in children with learning disabilities (“no discomfort”, “very mild discomfort” or “mild, insignificant discomfort”). The acceptability in children without learning disabilities was similar at 90% (n=183/204). When asked to rate the treatments as “successful” or “unsuccessful”, children, parent/carers and dentists rated the treatments as successful in 98%, 96% and 100% for children with learning disabilities respectively, and 98%, 97% and 99% for children without learning disabilities.

This study identified inequalities in the provision of dental care between children with learning disabilities and those without. It has shown the Hall Technique - a highly effective way of managing dental caries in children - to be a viable, acceptable and successful technique for managing disease for those children with learning disabilities. The Hall Technique is indicated as a treatment option for children with learning disabilities who have carious primary molars and may help to avoid treatment necessitating general anaesthesia or sedation.

Date of Award	2018
Original language	English
Awarding Institution	University of Dundee
Supervisor	Nicola Innes (Supervisor), John Radford (Supervisor) & Jenny C Harris (Supervisor)