• First check whether the casualty has a mild or severe case. Ask ‘Are you choking?’ If the person can reply, cough or breathe (or in a baby’s case cry) then the advice is to encourage the person to cough.
• If a person can’t speak, cough, cry or breathe, treat the incident as severe choking and follow the procedures from current first aid training, which is likely to include giving blows between the shoulder blades in the first instance. Other useful advice includes:
• Try to remove any loose bolus of food from the mouth. Call other staff for help. (If the person resists, he or she may injure you, rendering you unable to help. Also, other people may try to stop you if they misunderstand your intentions.) • If the person is wearing dentures, remove them.
(The person may not understand that you are helping and in fear may bite you.)
• Stay calm. Talk to the person and reassure him or her. Encourage big, deep coughs rather than shallow irregular ones if possible.
When the choking episode is over, try to reassure in a calm voice. The experience of choking is a very frightening one. Try to work out what caused the choking so that a similar incident can be prevented in the future.
• Poor dental hygiene and the build-up of plaque causes periodontal disease (gum disease).
• Direct acid attack of the teeth (particularly from acidic drinks such as fruit-based drinks) causes tooth erosion. People with learning disabilities have a higher level of untreated dental decay, more prevalent gum disease, more tooth extractions and poorer dental hygiene than the general population.16, 17 All research studies report
uniformly poor standards of oral hygiene and plaque control and poorer periodontal health in children with learning disabilities.18Little is known about the oral health
of adults with mild learning disabilities since many are not in contact with dental services, but studies in day centres and residential settings report higher levels of untreated disease than in the general population.19Infections of the
mouth lining occur easily and can cause considerable distress and difficulties with eating and drinking (eg. thrush in the mouth, cold sores and mouth ulcers).
Suggestions for the reasons behind the high levels of poor oral health include difficulties accessing dental services due to people’s challenging behaviour, or lack of NHS
treatment.17
Studies have also demonstrated a lack of knowledge, support and training about oral health available to family, friends and support staff of people with learning disabilities.20
Oral health care is often given a low priority by support staff21
and there is a shortage of training particularly in community-based and residential accommodation.22
Family and friends may be able to provide useful information on how to handle oral care. Historically, it has been reported that people with Down’s syndrome have a lower prevalence of caries due to late tooth eruption and abnormal tooth formation. However, more recent studies have shown that while caries incidence is lower among people with Down’s syndrome, it is not as low as it used to be since a higher percentage of people with Down’s syndrome are now living in the community setting rather than in institutions and have more access to foods and drinks that can cause caries (dental decay).23
People with Down’s syndrome are more likely to suffer from bruxism (grinding teeth) and gum disease. The tongue can be large relative to the size of the oral cavity and this can be a cause of badly aligned teeth.24
Gum disease can be severe in children with Down’s syndrome, even when oral hygiene is of a good standard. Hennequin et al25
have reported that, in France, people with Down’s syndrome had more oral health problems compared with their siblings and that, with age, the prevalence of chewing difficulties did not improve; the prevalence of bleeding gums and breathing through the mouth increased; but tongue protrusion decreased. In Sweden, a longitudinal study of oral health of adults with learning disabilities found that
those with Down’s syndrome had higher average annual loss of tooth-supporting bone compared with those people with other diagnoses.26
Poor oral hygiene and gum disease can put people at risk of transfer of bacteria into the bloodstream during some surgical or dental procedures. If the bacteria lodge in damaged or abnormal heart valves, life-threatening infection of the heart can result. Good oral health, of both teeth and gums, is therefore essential. In children with a learning disability, who may be slow to clear food or who may ‘pouch’ food in their mouth, as has been reported for some children with autistic spectrum disorder (ASD),27
there is a need for good oral hygiene both at home and at school.28
People with learning disabilities have fewer dentures provided for them than people in the general UK population, and those who do have them have increased problems with them related to poor dental hygiene.29
Frequent food and drink consumption allows little time for remineralisation of the teeth between snacks or meals and therefore those who may need to eat or drink ‘little and often’ should pay particular attention to their oral health.28
People who require higher-energy food supplements between meals and those who take sugar-based
medication will also have an increased risk of dental decay. People who take medication which causes dry mouth are also at greater risk of tooth decay. There may be some conflict between health professionals, family, friends and support staff when conflicting messages around oral health are given, for example, when high-sugar snacks are
recommended between meals to increase energy intake. It is important that health professionals consider the
consequences of their recommendations on other health messages and seek advice on how to manage this most effectively.
Tooth erosionis a progressive, irreversible loss of dental enamel usually caused by acids other than those produced by plaque bacteria. Erosion can lead to a reduction in the size of teeth and to tooth destruction. One of the main causes of tooth erosion is the frequent consumption of fruit juices, fruit drinks and fizzy drinks. Even those marked as ‘low-sugar’, ‘no added sugar’ or ‘diet’ can cause tooth erosion. Gastro-oesophageal reflux, vomiting and rumination can also contribute to tooth erosion.
A person with learning disabilities suffering dental pain may be unable to express discomfort and may exhibit a change in behaviour such as loss of appetite, unwillingness to participate in activities, sleeplessness, irritability or self- harm. It is important for family carers, friends and support staff to be alert to such changes and to find out if mouth or tooth pain is a possible cause of behaviour change.