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

P

roviding oral care to people with mental retardation requires 

adaptation of the skills you use every day. In fact, most people 

with mild or moderate mental retardation can be treated 

successfully in the general practice setting. This booklet will help you 

make a difference in the lives of people who need professional oral care.

Mental retardation is a disorder of intellectual and adaptive 

functioning, meaning that people who are affected are challenged 

by the skills they use in everyday life. Mental retardation is not a 

disease or a mental illness; it is a 

developmental disability that varies 

in severity and is usually associated 

with physical problems. While one 

person with mental retardation may 

have slight difficulty thinking and 

communicating, another may face 

major challenges with basic self-care 

and physical mobility.

Practical Oral Care 

for People With Mental Retardation

contents

Health Challenges IN

mental retardation 

and Strategies for 

Care

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

Mental challenges

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

Behavior challenges

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

Physical challenges

Cerebral palsy

Cardiovascular anomalies

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

Seizures

Visual impairments

Hearing loss and deafness

Oral Health

Problems IN Mental 

Retardation and 

strategies for care

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

Periodontal disease

Dental caries

Malocclusion 

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

Missing permanent teeth, 

delayed eruption, and 

enamel hypoplasia

Damaging oral habits

Trauma and injury

Additional Readings

Data indicate that 

people with mental 

retardation have more 

untreated caries and 

a higher prevalence 

of gingivitis and other 

periodontal diseases 

than the general 

population.
Many people with mental retardation 

also have other disabilities such as cerebral palsy, seizure or psychiatric disorders, 

attention deficit/hyperactivity disorder, or 

problems with vision, communication, and 

eating. Though language and communication problems are common in anyone 

with mental retardation, motor skills are 

typically more affected when a person has 

coexisting conditions.

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 Challenges. People with 

mental retardation learn slowly and often 

with difficulty. Ordinary activities of daily 

living, such as brushing teeth and getting 

dressed, and understanding the behavior of others as well as their own, can all 

present challenges to a person with mental 

retardation.

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. All should be aware of 

your patient’s mental challenges.

Reduce distractions in the operatory, 

such as unnecessary sights, sounds, 

or other stimuli, to compensate for 

the short attention spans commonly 

observed in people with mental 

retardation.

Talk with the parent or caregiver to 

determine your patient’s intellectual 

and functional abilities, then explain 

each procedure at a level the patient can 

understand. Allow extra time to explain 

oral health issues or instructions and 

demonstrate the instruments you will 

use.

Address your patient directly and with 

respect to establish a rapport. Even 

if the caregiver is in the room, direct 

all questions and comments to your 

patient.

Use simple, concrete instructions and 

repeat them often to compensate for any 

short-term memory problems. Speak 

slowly and give only one direction at a 

time.

Be consistent in all aspects of oral care, 

since long-term memory is usually unaffected. Use the same staff and dental 

operatory each time to help sustain 

familiarity. The more consistency you 

provide for your patients, the more 

likely they will cooperate.

Listen actively, since communicating 

clearly is often difficult for people with 

mental retardation. Show your patient 

whether you understand. Be sensitive to 

the methods he or she uses to communicate, including gestures and verbal or 

nonverbal requests.



Health Challenges in Mental 

Retardation and Strategies for Care
mental retardation

Behavior Challenges. While most 

people with mental retardation do not pose 

significant behavior problems that complicate oral care, anxiety about dental treatment occurs frequently. People unfamiliar 

with a dental office and its equipment and 

instruments may exhibit fear. Some react 

to fear with uncooperative behavior, such 

as crying, wiggling, kicking, aggressive 

language, or anything that will help them 

avoid treatment. You can make oral health 

care a better experience by comforting your 

patients and acknowledging their anxiety.

Talk to the caregiver or physician about 

techniques they have found to be effective in managing the patient’s behavior. 

Schedule patients with mental retardation early in the day if possible. Early 

appointments can help ensure that 

everyone is alert and attentive and that 

waiting time is reduced. 

Keep appointments short and postpone 

difficult procedures until after your 

patient is familiar with you and your 

staff.

Allow extra time for your patients to get 

comfortable with you, your office, and 

the entire oral health care team. Invite 

patients and their families to visit your 

office before beginning treatment. 

Permit the parents or caregiver to come 

into the treatment setting to provide 

familiarity, help with communication, 

and offer a calming influence by holding 

your patient’s hand during treatment. 

Some patients’ behavior may improve 

if they bring comfort items such as a 

stuffed animal or blanket.

Reward cooperative behavior with 

compliments throughout the 

appointment.

Consider nitrous oxide/oxygen sedation 

to reduce anxiety and fear and improve 

cooperation. Obtain informed consent 

from the legal guardian before administering any kind of sedation.

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.

People with mental retardation often 

engage in perseveration, a continuous, 

meaningless repetition of words, phrases, 

or movements. Your patient may mimic 

the sound of the suction, for example, 

or repeat an instruction over and again. 

Avoid demonstrating dental equipment if 

it triggers perseveration, and note this in 

the patient’s record.



Allow extra time 

for your patient 

to get comfortable 

with you, your 

office, and the 

entire oral health 

care team.
Physical Challenges. Mental 

retardation does not always include a 

specific physical trait, although many 

people have distinguishing features such as 

orofacial abnormalities, scoliosis, unsteady 

gait, or hypotonia due to coexisting conditions. Countering physical challenges 

requires attention to detail. 

Maintain clear paths for movement 

throughout the treatment setting. Keep 

instruments and equipment out of the 

patient’s way.

Place and maintain your patient in the 

center of the dental chair to minimize 

the risk of injury. Placing pillows on 

both sides of the patient can provide 

stability. 

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 to ease the 

transition. The patient or caregiver can 

often explain how to make a smooth 

transfer. (See Wheelchair Transfer: A 

Health Care Provider’s Guide, also part of 

this series.)

Some 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 provide support for the head and neck during care.

Cerebral palsy occurs in one-fourth 

of those who have mental retardation and 

tends to affect motor skills more than 

cognitive skills. Un­controlled body movements and reflexes associated with cerebral 

palsy can make it difficult to provide care.

Place and maintain your patient in the 

center of the dental chair. Do not force 

arms and legs into unnatural positions, 

but allow your patient to settle into a 

position that is comfortable and will not 

interfere with dental treatment.

Observe your patient’s movements and 

look for patterns to help you anticipate 

direction and intensity. Trying to stop 

these movements may only intensify 

the involuntary response. Try instead 

to anticipate the movements, blending your movements with those of your 

patient or working around them.

Softly cradle your patient’s head during 

treatment. Be gentle and slow if you 

need to turn the patient’s head.

Help minimize the gag reflex by placing 

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

Stay alert and work efficiently in short 

appointments.

Exert gentle but firm pressure on your 

patient’s arm or leg if it begins to shake.

Take frequent breaks or consider prescribing muscle relaxants when long 

procedures are needed. People with 

cerebral palsy may need sedation, general anesthesia, or hospitalization if 

extensive dental treatment is required.

Cardiovascular anomalies such 

as heart murmurs and damaged heart valves 

occur frequently in people with mental 

retardation, especially those with Down 

syndrome or multiple disabilities. To 

avoid complications, consult the patient’s 

physician and use the American Heart 

Association’s antibiotic prophylactic regimen (www.americanheart.org) for dental 

treatment when indicated.


mental retardation

Seizures are common in this population but can usually be controlled with 

anti­convulsant medications. 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, most commonly 

strabismus (crossed or misaligned eyes) and 

refractive errors, can be managed with careful planning.

Determine the level of assistance your 

patient requires to move safely through 

the dental 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 can 

also be accommodated with careful planning. Patients with a hearing problem 

may appear to be stubborn because of their 

seeming lack of response to a request.

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.



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.
In general, people with mental retardation 

have poorer oral health and oral hygiene 

than those without this developmental disability. Data indicate that people who have 

mental retardation have more untreated 

caries and a higher prevalence of gingivitis 

and other periodontal diseases than the 

general population.

Periodontal disease. Medications, 

malocclusion, multiple disabilities, and 

poor oral hygiene combine to increase the 

risk of periodontal disease in people with 

mental retardation. 

Encourage independence in daily oral 

hygiene. Ask patients to show you how 

they brush, and follow up with specific 

recommendations on brushing methods 

or toothbrush adaptations. Involve your 

patients in hands-on demonstrations of 

brushing and flossing.

Some patients cannot brush and floss 

independently due to impaired physical 

coordination or cognitive skills. Talk to 

their caregivers about daily oral hygiene. 

Do not assume that all caregivers know 

the basics; demonstrate proper brushing 

and flossing techniques. A power 

toothbrush or a floss holder can simplify 

oral care. Also, use your experiences 

with each patient to demonstrate 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.

Some patients benefit from the daily 

use of an antimicrobial agent such as 

chlorhexidine. Recommend an ap­propriate delivery method based on your 

patient’s abilities. Rinsing, for example, 

may not work for a patient who has 

swallowing difficulties or one who cannot expectorate. Chlorhexidine applied 

using a spray bottle or toothbrush is 

equally efficacious.

If use of particular medications has led 

to gingival hyperplasia, emphasize the 

importance of daily oral hygiene and 

frequent professional cleanings.

Dental caries. People with mental 

retardation develop caries at the same rate 

as the general population. The 

prevalence of untreated dental caries, 

however, is higher among people with 

mental retardation, particularly those 

living in noninstitutional settings.

Emphasize noncariogenic foods and 

beverages as snacks. Advise caregivers 

to avoid using sweets as incentives or 

rewards.

Advise patients taking medicines that 

cause xerostomia to drink water often. 

Suggest sugar-free medicine if available 

and stress the importance of rinsing 

with water after dosing.

Recommend preventive measures such 

as fluorides and sealants.

malocclusion. The prevalence of 

malocclusion in people with mental retardation is similar to that found in the general 

population, except for those with coexisting 

disabilities such as cerebral palsy or Down 

syndrome. A developmental disability in 

and of itself should not be perceived as a 

barrier to orthodontic treatment. The ability of the patient or caregiver to maintain 

good daily oral hygiene is critical to the 

feasibility and success of treatment.



Oral Health Problems in Mental 

Retardation and Strategies for Care

A developmental 

disability in and 

of itself should 

not be perceived 

as a barrier to 

orthodontic 

treatment.

Tips for caregivers are available in the booklet

Dental Care Every Day: A Caregiver’s Guide, also part of this series.
mental retardation

Missing permanent teeth, delayed

eruption, and enamel hypoplasia are 

more common in people with mental retardation and coexisting conditions than in people with 

mental retardation alone.

Examine a child by his or her first birthday and 

regularly thereafter to help identify unusual tooth 

formation and patterns of eruption.

Consider using a panoramic radiograph to determine whether teeth are congenitally missing. 

Patients often find this technique less threatening 

than individual films.

Take appropriate steps to reduce sensitivity and 

risk of caries in your patients with enamel hypoplasia.

Damaging oral habits are a problem for 

some people with mental retardation. Common 

habits include bruxism; mouth breathing; tongue 

thrusting; self-injurious behavior such as picking at 

the gingiva or biting the lips; and pica—eating objects 

and substances such as gravel, cigarette butts, or pens. 

If a mouth guard can be tolerated, prescribe one 

for patients who have problems with self-injurious 

behavior or bruxism.

TRAUMA and INJURY to the mouth from falls 

or accidents occur in people with mental retardation. 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.

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 mental retardation 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, Shapiro BK. Mental retar­dation. In 

Batshaw ML. Children With Disabilities (5th ed.). 

Baltimore, MD: Paul H. Brookes Publishing Co., 

2002. pp. 287–305.

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.

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.

Weddell JA, Sanders BJ, Jones JE. Dental problems 

of children with disabilities. In McDonald RE, Avery 

DR. Dentistry for the Child and Adolescent (7th ed.). 

St. Louis, MO: Mosby, 2000. pp. 566–599.



For more information about mental retardation, contact

National Institute of Child Health and Human 

Development Information Resource Center

P.O. Box 3006

Rockville, MD 20847

(800) 370–2943

www.nichd.nih.gov 

NICHDInformationResourceCenter@mail.nih.gov
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 mental retardation.

Other booklets in this series: 

Continuing Education: Practical Oral Care for People

 With Developmental Disabilities

Practical Oral Care for People With Autism

Practical Oral Care for People With Cerebral Palsy

Practical Oral Care for People With Down Syndrome

Wheelchair Transfer: A Health Care Provider’s Guide

Dental Care Every Day: A Caregiver’s Guide

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. 06–5194

Reprinted May 2006

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