Improving access to oral health care for those deprived of needed services should be of great concern to the dental profession. The rapid expansion of the elderly population, the presence of children with Special Health Care Needs SHCN, and the emergence of legislative guidelines for people of all ages with SHCN are three important factors that should prompt dentists to address cost-efficient ways to make their office facilities and operatory areas accessible for persons with SHCN.

Family involvement

  • The dentist should make a careful study of the family as to their strengths and weaknesses and the stresses and strains placed on each member.
  • When evaluating the situation prior to planning any care program, sit down and meet with the parents or caretakers to evaluate their intelligence, their dental IQ, their understanding of the child’s actual problems and prognosis, and their reasons for seeking dental care.
  • Parent’s opinions regarding the child’s previous dental experience and their reactions to such treatment is very important.
  • The dentist and auxiliaries should try to understand the anxious and frustrating times these parents have had.
  • Parents attitudes toward the handicapped child will many times dictate how the dentist approaches problem.
  • Fearful parents are often afraid that their child might be hurt. The overly protective parents may be ashamed of their child or be totally aware of the problems but not usually concerned. The ashamed parents might feel humiliated when they appear in public with their child, and if they are kept waiting in the reception area.

Preventive methodologies for the disabled

Expectations and motivation:

  • The values and interests of patients are varied and complex, particularly among the handicapped.
  • It is therefore important to tailor the educational approach to the needs and desires of each patient.
  • The goals should be, first of all, ones that are attainable. When an objective is set at an unrealistic level, failure to achieve soon frustrates the patient and he may abandon the effort.
  • Instructions to modify diet in ways that do not impose drastic changes in existing habits are much more likely to be realistic.
  • Objectives must be more meaningful and attractive to the patient and parent. An interest in the opposite sex will more likely motivate teenage patients to brush their teeth regularly than will fear of periodontal disease.

Home dental care

  • Dental education of parents/ guardians/caregivers is important to ensure children with SHCN do not jeopardize their overall health by neglecting their oral health.
  • Parents or guardian are initially responsible for establishing good oral hygiene at home.
  • Reinforcement must be provided through mass media (e.g. newspapers, radio, television, internet), communication with other people, and school activities (e.g. health classes, parent- teacher association meetings)
  • Regular follow up supervision at home and in office is essential.
  • Although independent brushing is not contraindicated, parents and staff should be aware that without their follow up, unsupervised oral hygiene procedures in children with SHCN can have serious dental consequences.
  • Horizontal scrub method is recommended for brushing because it is easy to perform and give good results.
  • This technique consists of performing gentle horizontal strokes on cheek, tongue and biting surface of all teeth and gums.
  • A soft multitufted nylon brush should be used.


For the purpose of teaching individual oral hygiene to handicapped persons, three groups are described by Bensberg et al

  1. The self care group- those able to brush their teeth but needing some encouragement and minimal supervision.
  2. The partial care group- those able to carry out only part of their oral hygiene needs and require considerable training and direct supervision to complete the job properly.
  3. The total care group- those unable to assist in any way in their own care and must be assisted by a second party


Self care group:

  • Easiest to work with.
  • Modifications may be required for patients with rheumatoid arthritis or chronic damage to the joints that results in an inability to close their hands.
  • Some patients may find it advantageous to have the size and weight of toothbrush handle increased.
  • Some patients with limited movement will also require a longer handle.
  • They may even learn to floss.


School program:

  • Self care group individuals will usually attend a special academic school or class, which can be valuable in motivating and educating them to take care of their teeth.
  • The teachers and or aides can cooperate with hygienists, dentists, caretakers, parents.
  • It might be advantageous to hold a planning meeting of teachers, hygienists, dentists, parents and any others involved at the beginning of such a program. Thus the individual will not be confused by inconsistent teaching methods.
  • It is necessary to see that they have a daily set routine for oral care whether in school or home.
  • The individuals should assume more and more responsibility for their own oral care the care of their brushes and floss aids as they receive and progress through their training.

Partial care group

  • Individuals in this group will generally be moderately and often retarded.
  • They usually require close supervision and direct assistance to perform the routine tasks of everyday living.
  • They usually brush only the front teeth.
  • Patients may not be able to see the long term benefits of brushing their teeth.
  • We will not be able to motivate partial care children by explaining that brushing their teeth is important to social and emotional well being. Instead they may have to be taught tooth brushing on the premise that it makes them handsome or beautiful or it ” keeps teeth from hurting”.
  • Do not expect rapid learning
  • Repeat each step of the task many times until it is mastered and then move on to next ste.
  • This group will require your patience.
  • Break the task into small easy to accomplish steps:

1.Hold the toothbrush with help.

  1. Put the brush in mouth with help.
  2. Make the brush strokes in the mouth with help.
  3. Make the brush strokes by self.
  4. Brush the teeth from beginning to completion by self on being told to do so.
  • Make up a fancy calendar and placing stars on the dates that they brushed or by providing tokens or accomplishments.
  • Routine is important- taught in the same place by same method, at the same time of the day.

Total care group

  • Many are profoundly retarded, confined to wheel chairs or bedfast.
  • They will need much individual instruction and help.
  • Many may not be able to use a dentrifice or rinse their mouths with water after brushing.
  • Studies by Smith and Blankship in 1964 and Neibel and Keough in 1972 found the electric brushes superior to conventional tooth brushes. Electric tooth brushes make it easier for the parent or caretaker to master brushing the individuals teeth. The vibration and noise tend to desensitize the patient for future dental appointments if followed by positive reinforcement while the design and colour is motivational.
  • This group will be more difficult to manage. Some persons reach a degree of proficiency that enables them to be promoted to the partial group.



  • In dealing with self care and partial care groups, the most important aspect of developing an effective preventive program is communication.
  • With total care group, in which a second party must provide the care, the most aspect positioning. By providing the caretaker with a clear field of vision of the oral cavity, proper positioning will make it easier to give care and easier to do a proper job.
  • Health professionals, parents, teachers and caretakers assisting these individuals must become familiar with the necessary techniques.


With a larger child or an adult the person doing the brushing or flossing may stand behind patient and cradle the patient’s head in one arm, holding the lower jaw open with the same hand and brushing or flossing with the other hand.

In case of extremely uncooperative patients, mouth props or several tongue blades taped together can be used.


Many mothers or caretakers feel more comfortable sitting on a sofa and having the patient lie with his head in the caretakers lap to accomplish the oral hygiene procedures.


The toddler or small child can often be easily handled with the parent or caretaker sitting on a chair without arms or on the toilet seat in the bathoom. The child is draoed across the patient’s lap with the head hanging down over one leg slightly to assist in opening the mouth. This position gives a clear view of the oral cavity.

Sitting on the floor:

For difficult to control patient the parents can easily restrain the child and get a clear view of his mouth, still maintaining a comfortable position, by having the child sit on the floor and draping their legs over child’s arms, cradling and stabilizing the child’s head between their legs.

Wheel chair patients:

The same type of procedure can be used as in standing position.; but because of the design of some types of chairs, an alternate approach from the front of the patient may be more effective.

Bedridden patients:

The approach for bedridden patients is somewhat reversal from the positions described above. The patient is approached from the front.