Dyspraxia and Oral Health
Dyspraxia is a type of neurodivergence and affects around 6% of the UK population (source: Dyspraxia Foundation).
It is not curable, and therefore dependent on self-management by the individual, although in some cases Occupational Therapy can provide a supporting role. Outwardly, it often manifests as difficulty in co-ordinating movement. This is due to a lack of translation of movement from thought to action. Dyspraxia can also affect “logic gateways” – which means that initially every single step may need to be demonstrated to the individual in order for them to follow and repeat a pattern. Dyspraxia does not represent a reduction in an individual’s intelligence, but more the ability to translate thinking into actions and movement, which can cause the individual considerable frustration at times.
For many individuals with Dyspraxia, the entire head and neck area tends to be very sensitive, much more so than that of an individual without Dyspraxia, meaning that any differences such as soreness or bruising may be described by the individual in terms much greater or more urgent than a clinical evaluation itself may indicate. These views should be taken into account as these differences can cause serious discomfort to the individual. It has been suggested that the use of a Thyroid collar when taking appropriate X-Ray views may be helpful as individuals have expressed the sensation of a sore throat or dry mouth for the next day or so following such imaging.
So how can we support tooth health?
1. Tooth brushing
As with the general population, preference between a manual and electric toothbrush is individual. However reasons for either selection depend on some additional factors:
- Over sensitivity to noise or vibration of an electric brush
- Forgetting to recharge an electric brush at regular intervals
- Some brushes have useful visual indicators and displays that feed back.
- Difficulty in holding or effectively manipulating a manual brush (even if adapted)
- Consistently using just the right level of pressure is difficult; some find it easier to get consistent results with a manual, or with an electric, based on experiencing both.
With a manual brush many individuals report difficulty in manipulating the brush effectively, causing trauma and bleeding to the gums and potentially a wearing-down of tooth tissue due to excessive pressure. This can be attributed to over-sensitivity to sensations within oral tissues, which many report to extend throughout their entire head and neck area. Clinically, inflamed or traumatised gum tissue, and abrasion to tooth surfaces are often found. This can be addressed using handle adaptations such as a pencil grip or a TePe Extra Grip Handle, using pressure-resistant designs such as the Wisdom Gum Protector (which has a hinge on the handle which snaps back when excessive force is exerted to avoid damage to the tissues). An alternative approach for those who continue to experience co-ordination difficulties even with adaptations, is to use a Dr. Barman’s SuperBrush – which comprises of a large 3-sided brush head which essentially encircles the whole tooth so a lower amount of overall dexterity is required.
Toothbrushing should be considered a "full concentration task" which requires the individuals undivided attention. Any distraction is likely to cause loss of position - potentially meaning some areas are left unbrushed.
With both types of toothbrush, reaching all areas effectively or remembering to brush all parts of the mouth effectively are found difficult by many. Visual indicators on electric brushes, or a small visual reminder sheet and timer for manual brushes can be very beneficial. Due to the likely increase in splayed bristles, it is advisable to change manual brushes or electric brush heads monthly rather than the usual three monthly intervals. A very helpful adjunct is the use of Disclosing Solution (normally in chewable tablet form) which most dental practices and larger chemists sell. This consists of a food dye compound which “sticks” to areas which still have plaque on them – very helpful to ensure that comprehensive tooth brushing is achieved.
2. Toothpaste
The zesty mint flavour of many types of toothpaste can be overwhelming to the senses, and when brushing at night can cause undesired overstimulation of the brain – very mild or alternatively flavoured toothpaste containing the 1450ppm of fluoride is preferable, and many “6+” children’s toothpaste do deliver this level of fluoride with a much reduced mint or alternative taste – watch out with the cheaper or unusual brands as some have contained sugar which completely defeats the point of tooth brushing. Some individuals give up on using toothpaste unsupervised, because they cannot find an appropriate product. It is very advisable that individuals with Dyspraxia use a 500ppm increased-fluoride mouthwash at other times of day eg after lunch, but not at the same time as brushing as toothpaste is effective by remaining on the tooth surfaces for a time after brushing (for the same reason spitting out or rinsing out with water is not recommended). Examples of 500ppm F mouthwashes are Duraphat, Pronamel and Swirl mouthwash. A number of off-the-shelf products only contain half this amount, as designed for the broader general population.
3. Flossing
Most individuals with dyspraxia report it impossible or near-impossible to effectively manipulate dental floss between the teeth – although attempts to do so with floss and interspace brushes should be encouraged as far as possible, and may provide better overall oral health even if not used in the optimal way. For reasons of dexterity, many do not perform interdental cleaning at all or look to non-manual alternatives such as a WaterPik to provide some degree of inter-dental or subgingival (below the gum line) cleaning although inferior to using mechanical methods such as flossing. Often individuals report of using mouthwash regularly to disguise odours as an alternative to inter-dental cleaning – and rely on regular hygienist visits to provide a baseline for maintenance.
4. Clinical care
A common pattern is for the individual to have scaling performed at check-ups occurring at 6 month intervals, combined with a hygienist appointment three months later for additional scaling to for Oral Health Instruction reinforcement. This helps the individual to have a good starting point for a below-optimal home care regimen. Individuals tend to report sensitivity or pain in the mouth related to things that can appear clinically very minor. Sometimes the opposite is true and an individual can have significant dental problems yet be unaware of the situation. Each individual normally knows through life experience whether they are oversensitive or under sensitive to sensations and changes in the oral cavity, so the clinician can benefit by asking this question. For complex dental case management such as orthodontics (braces) or treatment requiring planned multiple extractions, referral is often made to a Hospital Dental Service which has access to patient management measures not available to GDP’s.
The dental care setting can be important to an individual with dyspraxia – as certain settings can provide different messages or reassurance. Sometimes the environment, the dental team, or even such things as whether they can have a plastic or paper bib used as to their preference (particularly if the individual has an often-associated condition known as Tactile Defensiveness) can assist the calmness and compliance of the individual.
The clinician should encourage attempts at using the most appropriate oral hygiene products for the prevailing clinical need e.g. sustained use of dental floss / tape – as the product most likely to give the best outcome. However, if results are not ideal (or the individual reports serious difficulty in using the product) an alternative should be recommended on the next visit. Demonstrations and explanations should be very clear and go through every stage as an individual point, even stages that may seem apparent in general e.g. take the floss out of the box, open the lid on the floss, pull the floss out from the container to about 50cm, and use the cutter on in the container to cut off the length that you need…. With practice the individual can pick up the technique but the links need to be made at the outset. Supporting visual or printed material that the individual can take home to stick to the wall is very helpful, and highlighting or modifying elements of the document to make them individually appropriate will enhance compliance with the suggested technique.
Finally – in managing the dyspraxic patient a friendly but instructional manner is helpful, and approaching slowly towards the mouth with any instruments gives the individual time to prepare themselves rather than being in a shock / resistive situation.
Resources / References:
(1) Caged In Chaos (Updated Edition) 2005-2014 Victoria Biggs (Macmillan)
(2) British Dental Journal (Volume 205,3) Access to special care dentistry, part 4, education (A. Dougall and J. Fiske)
