More than 71 million seniors (including 26 million with disabilities) will reside in the United States in 2030.

In the coming years the United States will experience a burgeoning number of senior residents, including those with disabilities. A review of these developments and the dental and medical concerns in the delivery of dental services is presented.

Down syndrome and Alzheimer's disease: children grow older.

The co-morbidity of Down syndrome and Alzheimer's disease is an increased reality due to an increased life expectancy among individuals with Down syndrome and the very early onset of Alzheimer's disease in this population. In addition, deinstitutionalization and mainstreaming these patients into the general community setting has meant that individuals with Down syndrome are dependent upon neighborhood practitioners for needed dental services. This article presents a review of the natural history of Down syndrome and Alzheimer's disease, along with the particular signs and symptoms of individuals with these co-morbidities and the implications for dental practice.

Slipping through the cracks. Dental care for older persons with intellectual disabilities.

An increasing population of men and women with intellectual disabilities and other developmental disabilities is reaching older ages. As our country continues the process of deinstitutionalization, these individuals will require treatment in communities. Dental practitioners increasingly will be involved in the needs of this population, many of whom are members of families being treated in private dental practices. A review of these developments and the particular dental needs of these patients is considered.

Move of adults with mental retardation from institutions to community-based living: changes in the oral microbiological flora.

In the Western world, the policy of deinstitutionalization and integration of individuals with mental retardation is generally accepted. We tested the hypothesis that de-institutionalization may lead to changes of habits with a potential to influence oral health. When 57 adults with mental retardation moved from an institution to community-based living, their oral hygiene habits, gingival bleeding, and a three-day food record were registered one month before and 9 and 21 months after the move. Mutans streptococci and lactobacilli in saliva, P. intermedia/P. nigrescens, P. gingivalis, and A. actinomycetemcomitans in supragingival plaque, and C. albicans on mucous membranes were analyzed. After 21 months of community-based living, fewer persons showed high classes of mutans streptococci, growth of P. intermedia/P. nigrescens, and high frequency of sucrose intake, and more subjects showed growth of C. albicans. In a short perspective, the indicators of oral diseases suggest an unchanged or lower risk of oral diseases after the de-institutionalization of individuals with moderate or severe mental retardation.

Down syndrome: a review of the literature.

This review of the literature on Down syndrome focuses on various systemic anomalies and oral anomalies, its clinical manifestations, and recommendations for persons with Down syndrome. From the time Down syndrome was diagnosed by phenotype to the present when karyotyping distinguishes chromosomal subgroups, increasingly sophisticated tests and treatments have influenced the lives of Down syndrome patients. Medical advances, special educational programs, and increasing social acceptance of disabled people in the community have resulted in current trends of normalization and deinstitutionalization of these patients. Once a dentist is familiar with a patient's medical history and takes needed precautions, these patients can be treated routinely in a dental office.

Dental students' experiences with and attitudes toward people with mental retardation.

BACKGROUND: People with mental retardation have limited access to oral health care. Dental school administrators reported minimal training in U.S. dental schools for these patients. As a result, students and practitioners may not be prepared to provide needed services. METHODS: The authors surveyed 295 third- and fourth-year students at five dental schools about their didactic and clinical preparation for, attitudes toward and comfort levels with treating people with mental retardation, as well as whether their experiences affect their willingness to treat people with mental retardation. The authors analyzed data using previously developed statistical software. RESULTS: A little more than 68 percent of respondents reported receiving five hours or less of instruction devoted to how to care for people with mental retardation, and 50.8 percent reported having no clinical training in this area. Nearly 60 percent reported that they had little to no confidence in providing care, while 74.6 percent reported they had little to no preparation in providing care. Students who had experience working with people with mental retardation attributed greater capabilities to such people than did students who had no such experience. CONCLUSIONS: Many U.S. dental students are prepared inadequately to provide services for people with mental retardation. Spending time with these patients provides a more positive understanding of the capabilities of these people. PRACTICE IMPLICATIONS: Increasing numbers of people with mental retardation no longer live in institutions, and they are dependent on dentists in private practice for care. Increased dental school training and continuing education programs are needed to meet this need.

Survey of nursing and medical profile prior to deinstitutionalization of a population with profound mental retardation.

During the planning stages of deinstitutionalization, the importance of nursing services must be recognized and given priority consideration in the community placement of persons with serious developmental disabilities. The objective of this study was to survey the medical and nursing profile of a group of nonambulatory, institutionalized individuals with profound mental retardation in anticipation of their nursing and medical needs in the community. Data were collected from the Individual Habilitation Plans of 55 individuals who had resided in a residential facility for individuals with mental retardation and were scheduled for community placement Serious medical problems in decreasing frequency were constipation (96%), seizure disorder (70%), poor dental hygiene (67%), cerebral palsy (62%), scoliosis (61%), contractions (41%), aspiration (44%), skin lesions (40%), and dysphagia (22%). Considering the complexity of health issues encountered in this population, adequate nursing and medical planning are critical to the wellness and successful community placement of a population with special needs.

Dental care for the patient with bipolar disorder.

Chronic mental illness and its treatment carry inherent risks for significant oral diseases. Given the shift in treatment regimens from the traditional institutionally based approach to more community-focused alternatives, general dental practitioners can expect to see and be asked to treat patients with various forms of psychiatric disorders. One such group consists of patients with bipolar disorder (including type I bipolar disorder or manic-depressive disorder). The purpose of this paper is to acquaint the dental practitioner with the psychopathological features of bipolar disorder and to highlight the oral health findings and dental management considerations for these patients. Bipolar disorder is considered one of the most treatable forms of psychiatric illness once it has been diagnosed correctly. Through a combination of pharmacotherapy, psychotherapy and life-adjustment skills counselling, these patients are better able to understand and cope with the underlying mood swings that typify the condition and in turn to interact more positively and progressively within society as a whole. Both the disease itself and its various pharmacologic management modalities exact a range of oral complications and side effects, with caries, periodontal disease and xerostomia being encountered most frequently. It is hoped that after reading this article the general dental practitioner will feel more confident about providing dental care for patients with bipolar disorder and in turn to become a vital participant in the reintegration of these patients into society.

Dentists and community care.

April 1993 saw the introduction of the 'Community Care' element of the 1990 NHS and Community Care Act. The term 'Community Care' describes the relocation of long-stay hospital residents to community accommodation. Much public attention has recently been focused on the welfare of psychiatric patients in the community, in particular whether they currently receive adequate care and supervision.

Oral healthcare of clients with learning disability: changes following relocation from hospital to community.

OBJECTIVE: To investigate changes in the oral healthcare of adults with learning disability after transference from long stay hospital care to community-based care. SUBJECTS: Adults with learning disability who were former residents of a single long stay hospital and who had been resettled into the community during the period April 1995 to April 1998. DESIGN: Structured questionnaire with a covering letter sent to community-based carers. Hospital notes were reviewed to assess oral healthcare received as in-patients. RESULTS: There was a 68% response rate to the questionnaire from community-based carers with details obtained from 106 out of a possible 157 subjects. As residents in the hospital, all subjects were examined regularly by a dentist--yearly for edentulous and six-monthly for dentate individuals. However, attendance patterns were less regular as residents in the community. In the community, individuals were also less likely to receive operative dental treatment. Although oral hygiene regimes were generally on a daily basis only 37% of the subjects and/or their carers had received oral health education from dental professionals in the community. CONCLUSION: Changes from institutional living to community-based housing for adults with learning disability may be associated with changes in dental attendance and treatment patterns.

Move of adults with intellectual disability from institutions to community-based living: changes of food arrangements and oral health.

The policy of deinstitutionalisation, integration and increased independence for individuals with intellectual disability has been accepted in the western part of the world. The aim of the present study was to evaluate the changes in oral health and eating arrangements when intellectually disabled persons move from an institution to integrated living. In 55 subjects the incidence of caries and tooth mortality was compared 4.7 years before and after the change in living arrangements. In addition, changes in oral hygiene routines, eating arrangements and weight were registered. The incidence of caries and tooth mortality was low among individuals with severe and moderate intellectual disability during 4.7 years before as well as after de-institutionalisation, and no differences could be observed between the periods. After 4.7 years of integrated living, 40% of the subjects were estimated to have gained weight. Among those subjects with an estimated decreased weight (13%), the caries incidence was higher compared to other subjects with intellectual disability. Participation in grocery shopping and cooking increased in the integrated living. The increase in weight suggests an impact on general health after almost 5 years of integrated living. No indications of a corresponding influence on oral health in individuals with severe or moderate intellectual disability could be observed after deinstitutionalisation. However, oral health in weight-losing subjects need further investigations.

Studies on oral health in mentally retarded adults.

UNLABELLED: During the last decades, a new policy involving normalisation, integration, equality and deinstitutionalisation of mentally retarded (MR) individuals has been accepted in Sweden. Consequently, many institutions have been closed and an increased number of people with MR are now integrated into the Swedish community. The general aim of this thesis was to investigate if a greater degree of independence for MR adults influenced the prevalence of oral diseases. MATERIAL AND METHODS: The caries incidence and prevalence, number of remaining teeth, incidence of tooth mortality and interproximal bone loss were investigated in a group of MR adults, aged 21-40 years, all with protracted, regular preventive dental care. The studied variables were related to living arrangements and degree of MR, and were followed during 8.5 years (Papers I, II and VI). Incidence and reasons for tooth mortality were studied during 10 years in institutionalised MR individuals (Paper III). In connection with the closing-down of an institution for MR adults, the changes of oral hygiene habits, sucrose intake and oral microbiological flora were studied in the new integrated living (Papers IV and V). RESULTS: Less restrictive living arrangements and mild forms of MR were correlated to a high caries prevalence in persons with MR. After 8.5 years, the caries incidence had decreased in all subjects, but persons with mild MR and those who lived integrated still had a higher caries prevalence than other MR adults. With the exception of subjects with Down syndrome, the interproximal bone loss during 8.5 years was similar or lower compared to normal Swedish populations. Institutionalised MR subjects had lost an average of 3.72 teeth during 10 years. Periodontitis was the main reason for tooth mortality. Persons who cooperated well with dental treatment and those who used neuroleptics lost fewer teeth during the 10-year period compared to other MR individuals. The proportion of subjects with high levels of mutans streptococci and subjects who showed growth of P. intermedia/P. nigrescens decreased after deinstitutionalisation, and less subjects consumed sucrose frequently. The oral hygiene routines, and the levels of lactobacilli, P. gingivalis and A. actinomycetemcomitans were not influenced by the change in living arrangements. A simplified saliva sampling method, involving licking directly on the bacteria culture, was developed to count lactobacilli in saliva when delivering whole saliva was impossible. CONCLUSIONS: Less restrictive living and a mild degree of MR were correlated to a high caries prevalence. Subjects with poor ability to cooperate with dental treatment and those with Down syndrome have an obvious risk of deteriorated oral health. However, compared to normal Swedish populations, the MR subjects studied in this thesis had, after several years of regular dental care, satisfactory oral health.

Preventing dental disease for people with special needs: the need for practical preventive protocols for use in community settings.

People with disabilities have more dental disease, more missing teeth, and more difficulty receiving dental care than other members of the general population. Because of the deinstitutionalization movement during the later 20th century, many formerly institutionalized people now reside in community settings, which lack oral health services. Even individuals who were not institutionalized have barriers to oral health services. These realities underscore the importance of preventing dental disease in people with special needs by establishing preventive dental disease protocols.

A position paper from the Academy of Dentistry for Persons with Disabilities. Preservation of quality oral health care services for people with developmental disabilities.

As administrators, health care planners, and community-based non-dental professionals plan for care and placement of disabled clients into community settings, the Academy of Dentistry for Persons with Disabilities encourages the inclusion of dentistry as part of the process and urges that experienced institutional dental personnel be utilized, recognizing their vast experience and special skills related to providing for the oral health care of persons with disabilities.

Providing oral health care to individuals with severe disabilities residing in the community: alternative care delivery systems.

For some individuals with disabilities who reside in the community, comprehensive oral health care is inaccessible. This deficiency has been noted by health care professionals and advocacy organizations. For example, most dentists who provide care to people with disabilities who reside in the institutional setting perceive that present resources within the community, both private and public, are generally unprepared to provide comprehensive dental care to the adult with severe disabilities; they also believe that special facilities and programs are needed that will be geographically and financially accessible to these individuals. Fortunately, several "special programs" have been established that successfully provide dental care to this population. This article describes these alternative care delivery systems and discusses their characteristics, advantages, and disadvantages. In addition, given the continuing process of community placement, implications for institutional dental programs are presented.

Providing general dentistry for people with disabilities: a demographic review.

In the mid-1990s, approximately 54 million American people had some level of disability, including 26 million who had a severe disability. In addition, more than three-quarters of individuals with mental retardation/developmental disabilities were deinstitutionalized during the past 30 years and now reside in our communities, relying upon community practitioners for needed services. This review is provided to make dental practitioners aware of the magnitude and dimensions of the situations in which persons with special needs require their services.

The extraordinary vulnerability of people with disabilities: guidelines for oral health professionals.

In the last 40 years, there has been a dramatic shift in living arrangements for people with disabilities from large state institutions to community-based care. This shift has required communities to increase their clinical capacity including oral health care systems. Oral health professionals must be cognizant that the rate of abuse and neglect experienced by people with developmental disabilities and other special needs is at least four times the rate experienced by the general population. These trends have resulted in additional responsibility on community oral health professionals to provide oral health services for many people who formerly lived in state institutions including recognizing and reporting suspected abuse and neglect. Oral health professionals must prepare themselves to successfully carry out these professional responsibilities.

Dental disease prevention and people with special needs.

People with special needs are the most underserved of the underserved in our society. They have more dental disease, more missing teeth, and more difficulty obtaining dental care than other segments of the population. Many individuals and groups, including the authors of this paper, have developed community-based systems to improve oral health for people with special needs. However, these systems have not been as successful as they might be because of lack of effective preventive protocols specifically designed for people with special needs. This paper reviews strategies for overcoming informational, physical, and behavioral barriers to oral health and presents a summary of the results of a conference titled "Practical Preventive Protocols for Prevention of Dental Disease in People with Special Needs in Community Settings." The rationale for using an Oral Health Care Plan is presented as well as a sample plan. These strategies and protocols are designed to complement the system of supported community-based oral health care. The goal of this system is to help people with special needs enjoy a lifetime of oral health the same as other members of our society.

Dental care for individuals with developmental disabilities is expensive, but needed.

More than $35 billion in additional lifetime costs will be expended for all children in the United States born with mental retardation in 1998 alone. The figure is $4.7 billion for California children. These numbers include neither the costs for individuals with other developmental disabilities, nor the costs for dental services. Despite the findings that individuals with mental retardation have more untreated dental needs than individuals in the general population, most dental students and many practitioners have limited experience in providing care for patients with special needs. The significant additional general costs for the care of people with mental retardation and other developmental disabilities are a reality, but the dental profession must not lose sight of the need for its members to provide services for these individuals.

Community-based dental services for patients with special needs.

Deinstitutionalization of individuals with mental retardation and developmental disabilities has increased the demand for dental services for these patients by community practitioners. There are numerous difficulties associated with the delivery of care to this population with special needs. Nevertheless, a county-by-county review for New York State indicates that in most instances, if all dentists are willing to help, there would be a relatively small number of these patients per dental practitioner.