Oral health interventions in children and adolescents with special needs

Down Syndrome

Studies have reported that children with intellectual and developmental disabilities (IDD) have poorer health outcomes (including poorer oral health outcomes) compared to children without IDD. Intellectual disability (ID) occurs before the age of 18 years and causes substantial impairment of intelligence which results in reduced social functioning. Developmental disability (DD) can cause cognitive impairment, a reduction in physical functioning or both. DD is apparent before the age of 22 years. Recent meta-analyses to explore which oral health strategies were more effective in children and adolescents with IDD had notable flaws.

The aim of this systematic review and meta-analysis was to explore the effectiveness of different oral health education and promotion interventions for children and adolescents with IDD using gingival health, dental caries and oral-health related quality of life.


Searches were conducted in Medline, CINAHL, Cochrane Library, ERIC and PsychINFO for studies in English or in a language for which translation could be obtained. Inclusion criteria included children and adolescents up to 18 years of age with IDD and an oral health education or promotion intervention. Two reviewers independently assessed for risk of reporting bias (using the Cochrane Risk of Bias for Randomised Controlled Trials (RCT) (RoB2)) and publication bias (using the GRADE appraisal instrument). Disagreements were resolved by consensus. RCTs and non-randomised studies (NRSs) were included in the review. Meta-analyses were performed if there were more than two studies with similar outcome measures and they were carried out separately for NRSs and RCTs.


  • 18 studies were used for qualitative analysis and, from these, 11 studies were used for meta-analysis
  • 11 studies were RCTs and 7 studies were NRSs
  • 8 comparisons of different oral hygiene interventions were included; fluoride use, chlorhexidine dentifrices, modified toothbrushes, electric toothbrushes, yoga, talk and model oral hygiene instruction (OHI), toothbrushing instruction (TBI) and video modelling
  • 14 had an overall high risk of bias and 4 studies had “some concerns”
  • Fluoride compared with no fluoride
    • A low certainty RCT found fluoride reduced decayed missing and filled teeth (DMFT) (MD -0.96, 95% CI -1.93 to 0.01) [1 RCT, 142 participants]. The same study found little or no effect on the Debris Index (DI).
    • Another low certainty RCT found slightly reduced decayed missing filled surfaces (DMFS) increment per 100 surfaces with fluoride use (MD -0.45, 95% CI -1.77 to 0.87) [1 RCT, 119 participants]. The same study found little or no difference in the calculus index (CI).
  • Chlorhexidine dentifrices compared with control
    • Low certainty evidence found chlorhexidine dentifrices resulted in a large reduction in plaque index (PI) (10-30 days of follow up) (SMD -1.08, 95% CI -1.49 to -0.67) [4 NRSs and 3 RCTs, 282 participants)
    • The evidence regarding the effect of chlorhexidine dentifrices on gingival index (GI) is very uncertain
  • Modified toothbrushes compared with manual toothbrushes
    • Moderate certainty evidence found that modified toothbrushes gave a slightly reduced PI when measured using the Quigley Heim method (MD -0.38, 95% CI -0.86 to 0.1) [1 RCT, 25 participants]
  • Electric toothbrushes compared with manual toothbrushes
    • Very low certainty evidence found that electric toothbrushes gave a slight reduction in PI (SMD -0.84, 95% CI -1.8 to 0.12) [3 RCTs, 243 participants]
    • Very low certain evidence found electric toothbrushing reduced bleeding index (BI) (MD -0.2, 95% CI -5.78 to 5.38) [1 RCT, 106 participants)
  • Yoga and OHE compared with OHE
    • Very low certainty evidence found that yoga with OHE has little or no effect on PI (MD -0.03, 95% CI -0.13 to 0.07) [1 NRS, 67 participants]
  • Talk and model OHI compared with video OHI
    • Low certainty evidence found that talk and model demonstration based OHI gave a slight reduction in PI and GI [1 RCT, 100 participants]
  • TBI and OHE compared with OHE only
    • Very low certainty evidence found TBI and OHE is an “additional benefit” [1 RCT, 26 participants]
  • Video modelling compared with control video
    • Very low certainty evidence found video modelling has minimal effect [1 RCT, 20 participants]


The authors concluded: –

Conservative conclusions are drawn, echoing sentiments from a Cochrane review for normal child populations (de Silva et al., 2016), in that although various oral health interventions in individuals with IDD show some evidence of benefit, the certainty of this evidence is mostly low or very low, this high level of bias could be attributed to trials being conducted before CONSORT guideline implementation (Altman et al., 2001). Therefore, any adaptations made to oral health practices of individuals with IDD need to consider the unique situation of the patient and their caregivers.


The authors undertook a detailed search on a number of major databases. The studies mostly had very low and low certainty evidence and were ascribed a high risk of bias. Limitations on studies, such as small sample sizes, reduced the reliability of the results. Most of the studies included were published before guidelines, like CONSORT, were adopted and consequently, the quality of the outcomes varied greatly. This review intended to investigate the oral health related quality of life of participants, however, this was not reported on in the included studies. The authors note that this may reflect the lack of evidence in children and adolescents with IDD. Research in participants with IDD can be challenging due to a number of factors, such as varying levels of disability and the varying motivation of caregivers (who may ultimately be responsible for administering the oral health intervention). Further studies with larger sample sizes, more clearly defined outcomes and low risk of bias are important to improve the quality of research in children and adolescents with IDD.


Primary paper

Lai YYL, Zafar S, Leonard HM, Walsh LJ, Downs JA. Oral health education and promotion in special needs children: Systematic review and meta-analysis. Oral Dis. 2022 Jan;28(1):66-75. doi: 10.1111/odi.13731. Epub 2020 Dec 2. PMID: 33215786.

Other references

Dental Elf – 5th Jul 2019

Intellectual disability and oral health

Dental Elf – 3rd Nov 2017

Children and adolescents with intellectual disabilities: oral health status

Photo credits

Photo by Pavol Štugel on Unsplash



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