Developmental disabilities such as autism, cerebral palsy, Down syndrome, 

and mental retardation are present during childhood or adolescence and 

last a lifetime. They affect the mind, the body, and the skills people use 

in everyday life: thinking, talking, and self-care. People with disabilities often 

need extra help to achieve and maintain good health. Oral health is no exception.

Over the past three decades, a trend toward deinstitutionalization has brought 

people of all ages and levels of disability into the fabric of our 

communities. Today, approximately 80 percent of those 

with developmental disabilities are living in communitybased group residences or at home with their families. 

People with disabilities and their 

caregivers now look to providers in 

the community for dental services.

Providing oral care to patients 

with developmental disabilities 

requires adaptation of the skills 

you use every day. In fact, most 

people with mild or moderate 

developmental disabilities 

can be treated successfully in 

the general practice setting. 

This booklet presents an overview 

of physical, mental, and behavioral 

challenges common in these patients and 

offers strategies for providing oral care.

contents

Health Challenges 

and Strategies 

for Care

2 . . . . . . . . . . . . . . . . . . . . . 

Mental capabilities

Behavior problems

Mobility problems

3 . . . . . . . . . . . . . . . . . . . . . 

Neuromuscular problems

Uncontrolled body 

movements

Cardiac disorders 

Gastroesophageal reflux

4 . . . . . . . . . . . . . . . . . . . . . 

Seizures

Visual impairments

Hearing loss and deafness

Latex allergies

Oral Health

Problems and 

Strategies for Care

5 . . . . . . . . . . . . . . . . . . . . . 

Dental caries

Periodontal disease

6 . . . . . . . . . . . . . . . . . . . . . 

Malocclusion

Damaging oral habits

Oral malformations

Tooth eruption

Trauma and injury

7 . . . . . . . . . . . . . . . . . . . . . 

Additional Readings

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES l National Institutes of Health l National Institute of Dental and Craniofacial Research 

Practical Oral Care 

for People With 

Developmental 

Disabilities 

Continuing Education


Health Challenges and Strategies for Care

Before the appointment, obtain and review the patient’s medical history. Consultation with 

physicians, family, and caregivers is essential to assembling an accurate medical history. Also, 

determine who can legally provide informed consent for treatment.

Mental capabilities vary in people with developmental disabilities and influence how 

well they can follow directions in the operatory and at home.

Determine each patient’s mental capabilities and communication skills. Talk with caregivers about how the patient’s abilities might affect oral health care. Be receptive to their 

thoughts and ideas on how to make the experience a success.

Allow time to introduce concepts in language that patients can understand.

Communicate respectfully with your patients and comfort those who resist dental 

care. Repeat instructions when necessary and involve your patients in hands-on 

demonstrations.

Behavior problems can complicate oral health care. Anxiety and fear about dental 

treatment can cause some patients to be uncooperative. Behaviors may range from 

fidgeting or temper tantrums to violent, self-injurious behavior such as head banging. This 

is challenging for everyone, but the following strategies can help reduce behavior problems:

Set the stage for a successful visit by involving the entire dental team—from the receptionist’s friendly greeting to the caring attitude of the dental assistant in the operatory.

Arrange for a desensitizing appointment to help the patient become familiar with the 

office, staff, and equipment before treatment begins.

Try to gain cooperation in the least restrictive manner. Some patients’ behavior may 

improve if they bring comfort items such as a stuffed animal or a blanket. Asking the 

caregiver to sit nearby or hold the patient’s hand may be helpful as well.

Make appointments short whenever possible, providing only the treatment that the 

patient can tolerate. Praise and reinforce good behavior and try to end each appointment on a good note.

Use immobilization techniques only when absolutely necessary to protect the patient and 

staff during dental treatment—not as a convenience. There are no universal guidelines 

on immobilization that apply to all treatment settings. Before employing any kind of 

immobilization, it may help to consult available guidelines on federally funded care, your 

State department of mental retardation/mental health, and your State Dental Practice Act. 

Guidelines on behavior management published by the American Academy of Pediatric 

Dentistry (www.aapd.org) may also be useful. Obtain consent from your patient’s legal 

guardian and choose the least restrictive technique that will allow you to provide care 

safely. Immobilization should not cause physical injury or undue discomfort.

Mobility problems are a concern for many people with disabilities; some rely on a 

wheelchair or a walker to move around.

Observe the physical impact a disability has and how a particular patient moves. Look 

for challenges such as uncontrolled body movements or concerns about posture.

Maintain a clear path for movement throughout the treatment setting.

Focusing on 

each person’s 

specific needs 

is the first 

step toward 

achieving 

better oral 

health.


If you need to transfer your patient from a wheelchair to the dental 

chair, ask the patient or caregiver about special preferences such as padding, pillows, or other things you can provide. Often the patient or 

caregiver can explain how to make a smooth transfer.

Certain patients cannot be moved into the dental chair but instead 

must be treated in their wheelchairs. Some wheelchairs recline or are 

specially molded to fit people’s bodies. Lock the wheels, then slip a 

sliding board (also called a transfer board) behind the patient’s back to 

support the head and neck.

Neuromuscular problems can affect the mouth. Some people 

with disabilities have persistently rigid or loose masticatory muscles. 

Others have drooling, gagging, and swallowing problems that complicate 

oral care.

If a patient has a gagging problem, schedule an early morning 

appointment, before eating or drinking. Help minimize the gag 

reflex by placing your patient’s chin in a neutral or downward position.

If your patient has swallowing problems, tilt the head slightly to one 

side and place his or her body in a more upright position.

If you use local anesthesia, be sure your patient does not chew the 

tongue or cheek. A short-lasting form of anesthesia may work well.

Uncontrolled body movements can jeopardize safety and your ability to 

deliver dental care. Pay special attention to the following:

Treatment setting: Make the treatment setting calm and supportive. Place dental 

instruments behind the patient and carefully position other objects such as cords and the 

light above the dental chair.

Patient’s position: Determine in advance whether a patient will need to be treated in 

his or her wheelchair. If not, keep the patient in the center of the dental chair. Pillows 

can help maintain a comfortable position.

Your position: Observe the patient’s movements and look for patterns to help anticipate 

direction. Place yourself behind the patient and gently cradle the head to provide 

support. Rest your hand around the mandible. (See the illustration above.)

Cardiac DISORDERS can affect the delivery of oral health care. Many people

with Down syndrome, for example, have congenital heart disorders that place them 

at risk for bacterial endocarditis. Prescribe antibiotic prophylaxis when indicated

(www.americanheart.org). Contact your patient’s primary care physician if you have 

questions about the medical history.

Gastroesophageal reflux sometimes affects people with central nervous system 

disorders such as cerebral palsy. Teeth may be sensitive or display signs of erosion. 

Consult your patient’s physician about the management of reflux.

Place patients in a slightly upright position for treatment.

Talk with patients and caregivers about rinsing with plain water or a water and baking 

soda solution. Doing so at least four times a day can help mitigate the effects of gastric 

acid. Stress that using a fluoride gel, rinse, or toothpaste every day is essential.

Positioning for treating a patient in a wheelchair. 

Note the support a sliding board can provide. Sliding 

or transfer boards are available from home health 

care companies.

Make the 

treatment 

setting calm 

and supportive.


Seizures accompany many developmental disabilities. The mouth is always at risk 

during a seizure: Patients may chip teeth or bite the tongue or cheeks. Persons with 

controlled seizure disorders can easily be treated in the general dental office.

Consult your patient’s physician. Record information in the chart about the frequency 

of seizures and the medications used to control them. Determine before the appointment whether medications have been taken as directed. Know and avoid any factors that 

trigger your patient’s seizures.

Be prepared to manage a seizure. If one occurs during oral care, remove any instruments 

from the mouth and clear the area around the dental chair. Attaching dental floss to 

rubber dam clamps and mouth props when treatment begins can help you remove them 

quickly. Do not attempt to insert any objects between the teeth during a seizure.

Stay with your patient, turn him or her to one side, and monitor the airway to reduce 

the risk of aspiration.

Visual impairments affect many people with developmental disabilities.

Determine the level of assistance your patient requires to move safely through the office.

Use your patients’ other senses to connect with them, establish trust, and make treatment a good experience. Tactile feedback, such as a warm handshake, can make your 

patients feel comfortable.

Face your patients when you speak and keep them apprised of each upcoming step, 

especially when water will be used. Rely on clear, descriptive language to explain 

procedures and demonstrate how equipment might feel and sound. Provide written 

instructions in large print (16-point or larger).

Hearing loss and deafness sometimes occur in people with developmental 

disabilities.

Patients may want to adjust their hearing aids or turn them off, since the sound of some 

instruments may cause auditory discomfort.

If your patient reads lips, speak in a normal cadence and tone. If your patient uses a 

form of sign language, ask the interpreter to come to the appointment. Speak with this 

person in advance to discuss dental terms and your patient’s needs.

Visual feedback is helpful. Maintain eye contact with your patient. Before talking, 

eliminate background noise (turn off the radio and the suction). Sometimes people with 

a hearing loss simply need you to speak clearly in a slightly louder voice than normal. 

Remember to remove your facemask first or wear a clear face shield.

Latex allergies can be a serious problem. People who have spina bifida or who have 

had frequent surgeries are especially prone to developing an allergic reaction or a sensitivity 

to latex. An allergic reaction can be life threatening.

Ask patients and caregivers about the presence of a latex allergy before you begin 

treatment.

Schedule appointments for your latex-allergic or -sensitive patients at the beginning of 

the day when there are fewer airborne allergens circulating through the office.

Use latex-free gloves and equipment and keep an emergency medical kit handy.

Record in the 

patient’s chart 

strategies that 

were successful 

in providing care. 

Note your patient’s 

preferences and 

other unique 

details that 

will facilitate 

treatment, such 

as music, comfort 

items, and flavor 

choices.


Oral Health Problems and Strategies for Care

People with developmental disabilities typically have more oral health problems than 

the general population. Focusing on each person’s specific needs is the first step toward 

achieving better oral health.

Dental caries is common in people with developmental disabilities. In addition 

to discussing the problems associated with diet and oral hygiene, caution patients and 

caregivers about the cariogenic nature of prolonged bottle feeding and the adverse side 

effects of certain medications.

Recommend preventive measures such as fluorides and sealants.

Caution patients or their caregivers about medicines that reduce saliva or contain sugar. 

Suggest that patients drink water frequently, take sugar-free medicines when available, 

and rinse with water after taking any medicine.

Advise caregivers to offer alternatives to cariogenic foods and beverages as incentives or 

rewards.

Educate caregivers about preventing early childhood caries.

Encourage independence in daily oral hygiene. Ask patients to show you how they 

brush, and follow up with specific recommendations. Perform hands-on demonstrations 

to show patients the best way to clean their teeth.

If necessary, adapt a toothbrush to make it easier to hold. For example, 

place a tennis ball or bicycle grip on the handle, wrap the handle in 

tape, or bend the handle by softening it under hot water. Explain that 

floss holders and power toothbrushes are also helpful.

Some patients cannot brush and floss independently. Talk to caregivers 

about daily oral hygiene and do not assume that they know the basics. 

Use your experiences with each patient to demonstrate oral care techniques and sitting or standing positions for the caregiver. Emphasize 

that a consistent approach to oral hygiene is important—caregivers 

should try to use the same location, timing, and positioning.

Periodontal disease occurs more often and at a younger age in people with 

developmental disabilities. Contributing factors include poor oral hygiene, damaging oral 

habits, and physical or mental disabilities. Gingival hyperplasia caused by medications 

such as some anticonvulsants, antihypertensives, and immunosuppressants also increases 

the risk for periodontal disease.

Some patients benefit from the daily use of an antimicrobial agent such as chlorhexidine.

Stress the importance of conscientious oral hygiene and frequent prophylaxis.

Encourage 

independence 

in daily oral 

hygiene. 

Toothbrush adaptations


Malocclusion occurs in many people with developmental disabilities and may be 

associated with intraoral and perioral muscular abnormalities, delayed tooth eruption, 

underdevelopment of the maxilla, and oral habits such as bruxism and tongue thrusting. 

Malocclusion can make chewing and speaking difficult and increase the risk of periodontal 

disease, dental caries, and oral trauma. Orthodontic treatment may not be an option for 

many, but a developmental disability in and of itself should not be perceived as a barrier 

to orthodontic care. The ability of the patient or the caregiver to maintain good daily oral 

hygiene is critical to the feasibility and success of orthodontic treatment.

Damaging oral habits can be a problem for people with developmental disabilities. 

Some of the most common of these habits are bruxism, food pouching, mouth breathing, 

and tongue thrusting. Other oral habits include self-injurious behavior such as picking 

at the gingiva or biting the lips; rumination, where food is chewed, regurgitated, and 

swallowed again; and pica—eating objects and substances such as gravel, sand, cigarette 

butts, or pens.

For people who pouch food, talk to caregivers about inspecting the mouth after each 

meal or dose of medicine. Remove food or medicine from the mouth by rinsing with 

water, sweeping the mouth with a finger wrapped in gauze, or using a disposable foam 

applicator swab.

If a mouth guard can be tolerated, prescribe one for patients who have problems with 

self-injurious behavior or bruxism.

Oral malformations affect many people with developmental disabilities. Patients 

may present with enamel defects, high lip lines with dry gingiva, and variations in the 

number, size, and shape of teeth. Craniofacial anomalies such as facial asymmetry 

and hypoplasia of the midfacial region are also seen in this population. Identify any 

malformations and explain to the caregiver the implications for daily oral hygiene and 

future treatment planning.

Tooth eruption may be delayed in children with developmental disabilities. Eruption 

times are different for each child, and some children may not get their first primary 

tooth until they are 2 years old. Delays are often characteristic of certain disabilities such 

as Down syndrome. In other cases, eruption problems are attributable to the gingival 

hyperplasia that can result from medications such as phenytoin and cyclosporin. Dental 

examination by a child’s first birthday and regularly thereafter can help identify atypical 

patterns of eruption.Trauma and injury to the mouth from falls or accidents occur in people with seizure 

disorders or cerebral palsy. Suggest a tooth-saving kit for group homes. Emphasize to 

caregivers that traumas require immediate professional attention and explain the procedures 

to follow if a permanent tooth is knocked out. Also, instruct caregivers to locate any 

missing pieces of a fractured tooth, and explain that radiographs of the patient’s chest may 

be necessary to determine whether any fragments have been aspirated.

No 

developmental 

disability in 

and of itself 

should be 

perceived as 

a barrier to 

orthodontic 

treatment.


Physical abuse often presents as oral trauma. Abuse is reported more frequently in people 

with developmental disabilities than in the general population. If you suspect that a child 

is being abused or neglected, State laws require that you call your Child Protective Services 

agency. Assistance is also available from the Childhelp® USA National Child Abuse 

Hotline at (800) 422–4453 or the National Clearinghouse on Child Abuse and Neglect 

Information (http://nccanch.acf.hhs.gov).

Making a difference in the oral health of a person with a developmental 

disability may go slowly at first, but determination can bring positive results—

and invaluable rewards. By adopting the strategies discussed in this booklet, you 

can have a significant impact not only on your patients’ oral health, but on their 

quality of life as well.

Additional Readings

Batshaw ML. Children With Disabilities (5th ed.). Baltimore, MD: Paul H. Brookes 

Publishing Co., 2002.

Fenton SJ, Perlman S, Turner H, eds. Oral Health Care for People With Special Needs: 

Guidelines for Comprehensive Care. River Edge, NJ: Exceptional Parent, Psy-Ed Corp., 

2003.

Hannequin M, Veyrune J-L. Significance of oral health in persons with Down syndrome: 

a literature review. Developmental Medicine and Child Neurology, 41:275–283, 1999.

Horwitz SM, Kerker BD, Owens PL, Zigler E. Dental health among individuals with 

mental retardation. In The Health Status and Needs of Individuals With Mental Retardation. 

New Haven, CT: Yale University School of Medicine, 2000. pp. 119–134.

Klein U, Nowak AJ. Characteristics of patients with autistic disorder (AD) presenting for 

dental treatment: a survey and chart review. Special Care in Dentistry, 19(5):200–207, 

1999.

McDonald RE, Avery DR. Dentistry for the Child and Adolescent (7th ed.). St. Louis, MO: 

Mosby, 2000.

Southern Association of Institutional Dentists (SAID). A Self-Study Course for Dental 

Professionals at Institutions Serving People With Mental and Physical Disabilities. SAID, 1994 

with periodic updates. Available at <www.saiddent.org>. Accessed April 2004.

U.S. Public Health Service. Closing the Gap: A National Blueprint for Improving the Health 

of Individuals With Mental Retardation. Report of the Surgeon General’s Conference on Health 

Disparities and Mental Retardation. Washington, DC, February 2001.
For additional copies of this booklet, contact

National Institute of Dental and Craniofacial Research

National Oral Health Information Clearinghouse

1 NOHIC Way

Bethesda, MD 20892–3500

(301) 402–7364

www.nidcr.nih.gov

This publication is not copyrighted. 

Make as many photocopies as you need.

NIH Publication No. 06–5196

Reprinted May 2006

This booklet is one in a series on providing oral care for people 

with mild or moderate developmental disabilities. The issues and 

care strategies listed are intended to provide general guidance on 

how to manage various oral health challenges common in people 

with developmental disabilities.

Other booklets in this series:

Practical Oral Care for People With Autism

Practical Oral Care for People With Cerebral Palsy

Practical Oral Care for People With Down Syndrome

Practical Oral Care for People With Mental Retardation

Wheelchair Transfer: A Health Care Provider’s Guide

Dental Care Every Day: A Caregiver’s Guide

Acknowledgments

The National Institute of Dental and Craniofacial Research 

thanks the oral health professionals and caregivers who 

contributed their time and expertise to reviewing and 

pretesting the Practical Oral Care series.

Expert Review Panel

• Mae Chin, RDH, University of Washington, Seattle, WA

• Sanford J. Fenton, DDS, University of Tennessee, Memphis, TN

• Ray Lyons, DDS, New Mexico Department of Health, 

Los Lunas, NM

• Christine Miller, RDH, University of the Pacific, 

San Francisco, CA

• Steven P. Perlman, DDS, Special Olympics Special Smiles, 

Lynn, MA

• David Tesini, DMD, Natick, MA

NATIONAL INSTITUTE OF

DENTAL AND CRANIOFACIAL

RESEARCH

National Institute of Dental 

and Craniofacial Research

Centers for Disease Control 

and Prevention

National Institute of Child Health 

and Human Development

Special Care Dentistry