Introduction
Mental retardation (MR) refers to subaverage general intellectual functioning which originates during the development period and is associated with impairment in adaptive behaviour. General intellectual functioning means the results obtained by administration of standardized general intelligence tests for the purpose. The significant subaverage is defined as I.Q. of 70 or below on the standardized scale of intelligence. The adaptive behaviour is defined as the degree with which the individual meets the standards of personal independence and social responsibility in relation to his age and cultural environment [1]. The deficits in adaptive behaviour may be reflected in the three areas i.e. during infancy and early childhood, during childhood and adolescence and during late adolescence and adulthood [1].
Early in the 20th century, individuals with MR were generally isolated, rather than encouraged to lead fulfilling and healthy lives [2-4]. The last 40 y, however, have seen dramatic changes in sentiments regarding those with MR, resulting in a turn in public policy towards an emphasis on normalization and inclusion [5-7].
Oral and dental anomalies are a frequent accompaniment of mentally handicapped,which intern leads to improper functioning of stomatognathic complex. It has been reported that relatively poor oral hygiene and high level of periodontal disease in challenged children [8,9]. Dental diseases and its treatment present several problems in this group of patients. Large percentage of children with Down syndrome has a heart defect, dental caries or infection of the gingival or periodontal tissues may lead to bacterial endocarditis [10]. Simple dental procedures such as conservative or endodontic treatment may pose a serious risk. In mentally handicapped administrating Anesthesia, either local or general should be done under strict observation. Several agents including ketamine and enflurane have been found to induce seizures and are therefore contraindicated in cerebral palsy [11].
Individuals with MR, have poor oral health as compared to the general population [12]. The oral health of the individuals with MR is associated with severity, aaetiology, residential arrangements and age of the individual [13]. The prevalence estimates among those with MR reported in the literature, however, are subject to some of the same problems as the prevalence estimates of other health conditions
Identification of persons with mental retardation and affording them care and management for their disabilities is not a new concept in India. According to Persons with Disabilities Act (PWD), 1995 Mental retardation means a “condition of arrested or incomplete development of mind of a person which is specially characterized by sub-normality of intelligence”. As a matter of need and above all as a matter of right, has had its recognition only in recent times, almost after the enactment of the Persons with Disabilities Act (PWD), 1995 [14].
Article 41of the Constitution of India (1950) embodied in its clause the “Right to Free and Compulsory Education for All Children up to Age 14 y”. Schools for persons with mental retardation were established including an integrated school in Mumbai [15]. According to NSSO (National Sample Survey Organization) currently there are more than 3000 special schools running in India.
The American Association on Mental Retardation (AAMR) also known as the American Association on Intellectual Disabilities (AAID). The AAMR 2002 definition reads “Mental retardation is a disability characterized by significant limitations, both in intellectual functioning and in adaptive behaviour, as expressed in conceptual, social, and practical adaptive skills, the disability originating before the age of 18 years.
The first large scale attempt to collect information on the prevalence of developmental delays was made in the 47th round of survey by National Sample Survey Organization (NSSO).
Screening Procedure
A systematic method for identification and screening of persons with mental retardation has been developed by the NIMH (National Institute for the Mentally Handicapped). They include pre-natal, neonatal and post-natal diagnostic procedures [16]:
1. Pre-natal Procedures
a. Blood tests for the pregnant mothers for any anemic condition, diabetes, syphilis, Rh incompatibility and neural tube defects in the foetal stage.
b. Ultrasonography (during pregnancy) is carried out in the second trimester of pregnancy to detect certain disorders, such as - neural tube defects, hydrocephaly, cerebellar lesions, etc.
c. Amniocentesis is indicated in cases of foetal chromosomal aberration, congenital metabolic errors, severe Rh incompatibility etc.
d. Chorionic Villous Sampling.
2. Neonatal and Postnatal Screening and Diagnostic Procedure.
3. Blood and urine examinations are conducted in the neonatal period in all suspected cases and with a previous history of mental retardation in the family or cretinism.
a. Apgar score at one minute after delivery.
b. Urine screening for metabolic errors -PKU (Phenyl Ketoneuria).
c. Blood biochemistry tests for cretinism, rickets, jaundice.
d. Blood antibody titres to detect infections.
e. Chromosomal analysis for Down syndrome, deletion of syndromes.
f. Neonatal neurobehavioural assessments.
g. Screening for visual impairments (visual acuity, fundus examination, and retinoscopy).
h. Screening for hearing impairments (Tympanogram, BERA.)
i. Ultra Sound Examination: To detect displacement of brain midline structures, thickness of brain substance, intracranial hemorrhage, etc in the newborn.
j. Biochemical Tests for identifying metabolic disorders.
k. Electro Encephalography (EEG): EEG is a useful diagnostic procedure for epilepsy, encephalitis, severe degree of mental retardation, etc.
l. Computerised Tomography (CT): CNS CT is useful to detect congenital anomalies like holoprosencephaly, agenesis of corpus callosum, Arnold chiari malformations, etc.
m. Magnetic Resonance Imaging (MRI): for intra-cranial pathology and structural abnormalities.
Screening Schedule I (NIHM National Institute of Mentally Handicapped) [16] [Table/Fig-1]
If an answer to any of the above items is ‘yes’, then suspect mental retardation.
• Compared with other children, did the child have any serious delay in sitting, standing or walking? Does the child appear to have difficulty in hearing?
• Does the child have difficulty in seeing?
• When you tell the child to do something, does he seem to have problems in understanding what you are saying?
• Does the child sometime have weakness and/or stiffness in the limbs and/or difficulty in walking or moving his arms?
• Does the child sometimes has fits, becomes rigid, or lose consciousness?
• Does the child have difficulty in learning to do things like other children of his age?
• Is the child not able to speak at all? (Cannot make himself understand in words/say any recognizable words).
• Is the child’s speech in any way different from normal? (Not clear enough to be understood by people other than his immediate family).
• Compared to other children of the same age, does the child appear in any way backward, dull or slow?
Selecting Appropriate Screening Measures [17]
For screening or an early detection program, appropriate screening measures must be selected.
• A screening device should meet the technical criteria of standardization, reliability, validity, and normative data.
• The screening instrument should also be culturally appropriate, acceptable to the participants and cost effective.
• Screening tests must have established sensitivity and specificity to be valid.
The World Health Organization (WHO), American Association for Mental Retardation (AAMR), American Association on Mental Deficiency (AAMD), International Classification on Deficiency (ICD), Diagnostic and Statistical Manual (DSM-IV) definitions of mental retardation relate to three levels of prevention [18]:
• Primary level of prevention is carried out by doctors and health professionals to prevent manifestation of the disability.
• Secondary level prevents the manifestations of additional disabilities and regression.
• Tertiary level mitigates the impact of disability on social isolation, stigmatization of the handicap.
Prenatal Prevention relates to-
• Dealing with causal factors such as Rhincompatibility; maternal illness, infections and other high risk conditions, such as malnutrition in mother and child during the first trimester of pregnancy, environmental and occupational hazards and consanguinity.
• Prenatal diagnosis where preliminary investigations are carried out, blood and urine tests investigations to assess the foetal abnormalities through ultrasonography, radiography, and amniocentesis.
• Immunization to the mother for preventing illnesses and infections leading to disability in the fetus.
Natal Prevention relates to-
• Delivery conducted under hygienic conditions by a trained person and/or in a hospital, to prevent breech delivery, asphyxia, prematurity with low birth weight, occurrence of jaundice, and other post-illnesses in the child.
• Care of new born at high risk for mental retardation in well equipped neonatal intensive care units; a close follow up to identify delays and abnormalities in development; facilitating intervention sand corrections at the earliest there by reducing the severity of handicap.
Postnatal Prevention relates to-
• Neonatal screening with simple blood and urine tests for metabolic abnormalities and hypothyroidism, associated conditions that lead to mental retardation.
Parent Training Programs
NIMH had initiated and conducted training programs for groups of parents. The intention in this model is to empower the parents and family members to look after their children with mental retardation as against providing expensive institutional support or residential programs [19].
The Persons with Disabilities Act, 1995
India was the first country to be a signatory to the Proclamation on the Full Participation and Equality of People with Disabilities in the Asian and Pacific Decade of Disabled Persons 1993-2002. In January 1996 an Act of Parliament enabling implementation of this Proclamation was passed The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995. Two other legislations, the Rehabilitation Council of India Act, 1992 and the National Trust Act, 1999 have included training and guardianship respectively in their clauses [14].
Technology for People with Mental Retardation and Associated Disabilities Assistive Technology (AT) can be a device or a service. An assistive technology device is any item, piece of equipment, or product system that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. An assistive technology service means any service that helps an individual with a disability select, acquire, or use an assistive technology device (Assistive Technology Act of 2004) [20].
Kelker (1997) developed the following is the list indicating that assistive technology may be considered appropriate when it does any or all of the following things [21]:
• Enables an individual to perform functions that can be achieved by no other means.
• Enables an individual to approximate normal fluency, rate, or standards – a level of accomplishment that could not be achieved by any other means.
• Provides access for participation in programs or activities which otherwise would be closed to the individual.
• Increases endurance or ability to preserve and complete tasks that otherwise is too laborious to be attempted on a routine basis.
• Enables an individual to concentrate on tasks – learning/employment, rather than mechanical tasks.
• Provides greater access to information.
• Supports normal social interactions with peers and adults.
• Supports participation in the least restrictive educational environment.
There is a complex interrelationship between socio-economic factors, illness, its treatment and oral health. Cost and fear are the most commonly cited barriers to dental care [22]. Both mental and physical illness cause deterioration of health and oral health is given least priority.
Such individuals should be informative and supportive so as to live a healthy and quality life with special care of oral health.
Factors which influence oral health, mitigate against self care and affect routine access and provision of oral care include [22]:
• Type, severity and stage of mental illness
• Client’s mood, motivation and self-esteem
• Lack of personal perception of oral health problems
• Client’s habits, life-style and ability to sustain self-care and dental attendance
• Environmental factors which mitigate against preservation of self-care
• Socio-economic factors which limit choices for healthy living
• Language and culture
• Lack of information on how to access information or dental services
• Oral side-effects of medication in particular the impact of xerostomia (dry mouth)
• Attitudes to oral care and knowledge of health professionals and health care workers
• Dental team’s attitudes and knowledge of mental health problems
• Local dental personnel unable or unwilling to provide adequate dental care
Oral Symptoms Associated with Psychiatric Disorders
Oral symptoms such as excessive palatal erosion, facial pain, and self inflicted injury are commonly seen in mentally retarded patients [23]. Enamel erosion is frequently reported in patients with anorexia and bulimia [24]. A third of patients attending a temperomandibular joint dysfunction clinic had evidence of a mental disorder [25]. High rates of psychiatric disorders are reported in patients attending a specialist pain clinic [26]. Burning mouth syndrome includes anxiety and depression as an aetiological factors [27].
Mood, Motivation and Behaviour
These are important factors that influence compliance with oral self-care and all aspects of personal hygiene, this is particularly notable in individuals suffering from dementia or memory loss [28]. Lack of interest and low self esteem associated with the disorder are factors that contribute to inadequate self-care and regular dental attendance. Depression is also often associated with a disinterest in oral self care [29].
Ability to Accept Dental Care
This is related to a number of factors such as mood, motivation, self-esteem, ability to think logically, accept and understand the treatment plan, and ability to cooperate with dental treatment. Dementia affects an individual’s ability to accept dental care [28]. Factors such as fear, anxiety and dental phobia plays vital role in acceptance of dental care and also the delaying of dental care.
Side Effects of Medication
Oral and systemic side effects of medication may prejudice oral health and give rise to patient management problems in planning treatment [30]. Reduction in salivary flow (xerostomia) is a frequently seen, as a result of which dental caries, periodontal problems, candidiasis, glossitis, stomatitis and parotitis are can be observed which in turn causes hindrance in chewing, speaking, trauma due to denture.
This may present as difficulty with speech, chewing, swallowing, poor denture tolerance, problems with retention and stability of dentures or denture trauma.
It is reported that subjects respond to xerostomia by an increased intake of candy and chewing gum to promote salivation and by a greater consumption of cariogenic fluid to slake their thirst [30,31]. Dyskinesia and dystonia are distressing side effect of long term anti-psychotic medication, characterized by abnormal, involuntary movement of the tongue or facial muscles, sometimes associated with abnormal jaw movements. Tongue protrusion and retraction, and facial grimacing are frequent presentations [32]. These symptoms pose problems for patient, career and the dental team in providing routine dental care [Table/Fig-2,3,4].
Lifestyle Factors
Healthy lifestyle, attitudes to and value of oral health, knowledge of oral disease, inability or unwillingness to accept treatment, low perception of dental treatment needs and mistrust of dental health professionals contribute to poor oral health. Diet has a significant impact on both oral and general health. Poor diet and an increased sugar intake in drinks are reported [30]. Housing conditions, homelessness, and access to privacy for personal hygiene are issues which influence personal care. Alcohol and drug use adversely affect oral health and the combination of alcohol consumption and cigarette smoking poses a high risk for oral cancer [33]. In people who misuse alcohol, there may also be folate deficiency or anemia with glossitis, angular cheilitis or recurrent apthae [34]. Smoking leads to an increased incidence of periodontal disease, particularly necrotizing gingivitis, candidasis and xerostomia. Erosion, cervical abrasion, gingival laceration and occasionally gingival necrosis and mucosal lesions are reported in oral cocaine users [35-37].
Professional Barriers
Attitudes to and knowledge of causes and effects of oral disease among health professionals and healthcare workers are issues which need to be addressed in reducing barriers to oral health. The knowledge and skill of the dental team in managing patients with mental health problems has been cited as barrier [38]. Low tolerance on the part of dental staff in dealing with clients’ lack of compliance with oral hygiene, care of prostheses and other issues and the unwillingness or inability of local dental personnel to provide adequate dental care is reported [39,40]. Dental team should be aware of the problems faced by mental handicapped, dentist should have good patient management skills, and a sympathetic attitude, these factors helps to develop a health relation with the mentally handicapped.
Professional Training
All health personnel should receive training to support the concept of primary oral health care [41]. Lack of knowledge of oral and dental disease, awareness or oral need, oral side-effects of medication and organization of dental services are highlighted in the literature [42-45]. Lack of formal training in oral health for professional careers is reported. Training programmes for health professionals both pre and post-qualification need to be urgently addressed.
Oral health professional should be well trained into knowledge, understanding about various conditions and its impact on the mentally retarded people and maintenance of oral health. Dental professionals should be updated with risks associated with drugs and treatments rendered to the mentally retarded patients. Improved behavioural management and communication skills can help the oral health professionals in providing quality oral health services to these people.
Oral Health Promotion
Preventive programmes need to be tailored to meet the individual needs with different diagnoses, prognoses, severity, stages of mental health and developed support and from the multidisciplinary team. Preventive advice for family members is paramount, which include instruction on the proper care and use of prosthetic devices for the needy. Advice on the importance of sugar free diet and to get relieve from the symptoms of dry mouth are essential to reduce the adverse oral side effects of anti-psychotic medication causing xerostomia.
Health promotion programmes developed in partnership with health, social and voluntary agencies should be client centered, tailored to meet their needs and with equal access [46]. It is reported that people with mental illness are often excluded from health promotion activities as they are perceived to be a nuisance [47]. The common risk factor approach with the dental team linking in to preventive programmes for promoting health is likely to be more effective, e.g.
a. To promote good mental health (information on accessing services including dental services)
b. To promote healthy eating including reduction of dietary sugars (dental decay)
c. Smoking cessation policies (periodontal disease and oral cancer)
d. Decrease alcohol intake (oral cancer, dental erosion)
It is recommended that an oral health needs assessment is included in general health assessment [48-50]. Such programmes provide the opportunity to include dietary advice which promotes general and oral health in the context of skills for daily living.
Coordinated Efforts–Governmental and Non-Governmental Organizations
In view of the vast multiplicity of agencies that would inevitably be involved in the implementation of the technology benefits to the persons with mental retardation, a coordinated and sustained effort is needed by both the governmental and non-governmental organizations [51].
A barrier-free environment is yet to be made available at all public places for persons with mental retardation and associated disabilities and locomotor disabilities.
• Facilities for comfortable travel even for short distances and for transporting the wheel chair are also not commonly available.
• Wheel chair usage, relating to postural stresses, calls for sustained research, development and design activities.
• Demand for walkers, motorized or self-propelled, may increase for use by persons with disabilities and the aged. Kerb-cuts and wheel chair usable roads and pavements are yet to be facilitated.
• Not all public buildings are disabled friendly. Provision of ramps, wide doorways, avoidance of split levels, provision of Braille signboards, toilet facilities, special locking and unlocking systems, are not prioritized or made mandatory.
• Only in specific situations and only as a result of litigations the transportation and conveyance – bus, rail and air has been made accessible to persons with disabilities.
• Possibilities of building wireless signals into lamp posts, signal posts which could provide positional, locational and directional information to road and pavement users through personal devices that incorporate navigational facilities are yet to make a beginning.
Screening Schedule I (NIHM National Institute of Mentally Handicapped)
| Stage Number | Child progress | Normal Development | Screening Schedule I If not achieved by the period |
|---|
| 1 | Responds to name / voice | 1-3 months | 4th month |
| 2 | Smiles at others | 1-4 months | 6th month |
| 3 | Holds head steady | 2-6 months | 6th month |
| 4 | Sits without support | 5-10 months | 12th month |
| 5 | Stands without support | 9-14 months | 18th month |
| 6 | Walks well | 10-20 months | 20th month |
| 7 | Talks in 23 word sentences | 16-30 months | 3rd year |
| 8 | Eats/drinks by self | 2-3 years | 4th year |
| 9 | Tells his name | 2-3 years | 4th year |
| 10 | Has toilet control | 3-4 year | 4th year |
| 11 | Avoids simple hazards | 3-4 year | 4th year |
| Other factors |
| 12 | Has fits | Yes | No |
| 13 | Has physical disability–what? | Yes | No |
Rehabilitation Council of India- Disability Development in India 2005, New Delhi.
| Level of Retardation | IQ Range | Approximate percentage of persons with mental retardation |
|---|
| Stanford- Binet and Cattell Tests | Wechsler Scales |
|---|
| Mild | 52 – 67 | 55-69 | 89 |
| Moderate | 36 – 51 | 40-54 | 7 |
| Severe | 20 – 35 | 25-39 | 3 |
| Profound | 0 – 19 | 0-24 | 1 |
The main side effects of drugs used in mental health that are relevant to the provision of oral care are listed below [32]
| Xerostomia | Drowsiness | Agranulo- cytosis | Tardive Dyskinesia | Tremor | Syncope | Hypo-tension | Thrombo- cytopenia | Immuno- suppression | Apathy |
|---|
| AMITRYPTILINE (TCA’S | ✓ | | | | | | ✓ | ✓ | ✓ | |
| BENZODIAZEPINES | ✓ | ✓ | | | | | ✓ | | | |
| CHLORPROMAZINE (Largactil) | ✓ | ✓ | | | | | ✓ | | | ✓ |
| CHLORDIAZEPOXIDE (Librium) | | ✓ | | | | | | | | |
| CLOZAPINE | Hyper salivation | | | ✓ | | | | | | |
| DEXAMPHETAMINE SULPHATE | ✓ | | | ✓ | | | | | | |
| DOTHIEPIN (Prothiaden) | ✓ | | | | | | | | | |
| FLUPHENAZINE DECANOATE | ✓ | ✓ | | ✓ | | | | | | |
| FLUOXETINE (Prozac) | | | | | | | | | | Aggression |
| HALOPERIDOL | ✓ | ✓ | | | | | | | | |
| LITHIUM CARBONATE | ✓ | | | | ✓ | ✓ | | | | |
| LOFEPRAMINE | ✓ | | | ✓ | ✓ | | | | | |
| METHYLPHENIDATE HYDROCHLORIDE (Ritalin) | ✓ | | | | ✓ | | | ✓ | | |
| MONO-AMINE OXIDASE INHIBITORS | ✓ | | | | | | ✓ | ✓ | ✓ | |
| PROCHLORPERAZINE (Stemetil) | ✓ | ✓ | | ✓ | | | ✓ | | | |
| PROCYCLIDINE | ✓ | ✓ | | | | | | | | |
| PROMAZINE HYDROCHLORIDE | ✓ | ✓ | | | | | | | | ✓ |
| ISPERIDONE | ✓ | ✓ | | | | | | | | ✓ |
| THIORIDAZINE (Melleril) | ✓ | ✓ | | | | | | | | ✓ |
Side effects of medication affecting management or oral health Scully, C and Cawson, RA. Medical problems in Dentistry: Wright 4th Edn. 1998
| Drug 1 | Drug 2 | Interaction |
|---|
| AMYTRIPTILINE | Anxiolytics & hypnotics Sympathomimetics Local anaesthetic with adrenaline | Enhanced sedative effects Potentiates drug 2 Increased heart rate and blood pressure |
| CANNABIS | Local Anaesthetic With Adrenaline | Abnormal response to local anaesthetic |
| CHLORPROMAZINE (Largactil) | Anxiolytics and Hypnotics Analgesics and Anaesthetics | Enhanced sedative effects Potentiation of drug 2 |
| CHLORDIAZEPOXIDE (Librium) | Opioid Analgesic Antihistamine | Enhanced sedative effects |
| CLOZAPINE | CARBAMAZEPINE COTRIMOXAZOLE ANXIOLYTICS and HYPNOTICS | Increased incidence of agranulocytosis Increased incidence of agranulocytosis Enhanced sedative effects |
| DEXAMPHETAMINE SULPHATE | ADRENALINE | Possible hypertension |
| DOTHIEPIN (Prothiaden) | ANXIOLYTICS and HYPNOTICS | Enhanced sedative effects |
| FLUOXETINE (Prozac) | ANTICOAGULANTS (Warfarin) | Potentiation of drug 2 |
| FLUPENTHIXOL DECANOATE(Depixol) | ANXIOLYTICS and HYPNOTICS | Enhanced sedative effects |
| FLUPHENAZINE DECANOATE (Modecate) | ANXIOLYTICS and HYPNOTICS | Enhanced sedative effects |
| HALOPERIDOL | CARBAMAZEPINE ANXIOLYTICS and HYPNOTICS | Accelerates metabolism Enhanced sedative effects |
| METHYLPHENIDATE HYDROCHLORIDE (Ritalin) | ADRENALINE | Possible hypertension |
| PROCHLORPERAZINE (Stemetil) | ANXIOLYTICS and HYPNOTICS | Enhanced sedative effects |
| PROCYCLIDINE | ANTIFUNGALS ANTIHISTAMINE | Reduced absorption Increased antimuscarinic effects |
| PROMAZINE HYDROCHLORIDE | ANXIOLYTICS and HYPNOTICS | Enhanced sedative effects |
| RISPERIDONE | ANXIOLYTICS and HYPNOTICS | Enhanced sedative effects |
| THIORIDAZINE (Melleril) | ANXIOLYTICS and HYPNOTICS | Enhanced sedative effects |
Illustrates the interactions that are described in the referenced literature, which may occur between drugs used to treat mental illness and those used in dentistry. Drug 1 is the mental health drug, and drug 2 is a drug of dental relevance [32]
Conclusion
Identification of persons with mental retardation and affording them care and management for their disabilities is an urgent need of time. Attitude and knowledge of the oral health professionals and is of utmost importance while rendering the oral health care to mentally handicapped people. Dental team should be aware of the problems faced by mental handicapped, dentist should have good patient management skills, and a sympathetic attitude, these factors helps to develop a health relation with the mentally handicapped. With the advancements that we see today it is important that full support and information should be provided to every individual to as to help him to live a better quality of life.
Illustrates the interactions that are described in the referenced literature, which may occur between drugs used to treat mental illness and those used in dentistry. Drug 1 is the mental health drug, and drug 2 is a drug of dental relevance [
32]
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