A biopsychosocial approach to functioning, oral health and specialist dental health care in children with disabilities – Swedish and international perspectives

Abstract: Introduction: Maintaining good oral health may be more important for children with disabilities than others, since problems with oral health may increase the impact of a disability, or the medical condition may increase the risk for poor oral health. In addition, the risk for oral health problems may be influenced by the functioning of the child. Functioning can also affect the child’s ability to cooperate in the dental setting, and how dental treatment is performed. A medical diagnosis alone does not provide enough information about a child’s functioning, nor oral health. Thus, there is a need for a holistic perspective of oral health and dental health care in children with disabilities. The International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) enables a structured assessment of the biopsychosocial consequences of a health condition.Aim: The overall aim of this thesis was to investigate how biopsychosocial factors relate to oral health and specialist dental health care in children with disabilities in a Swedish, and an international context, with special focus on the experience of dental treatment under general anaesthesia (DGA).Material and methods: The research was conducted using a quantitative, cross-sectional, comparative and descriptive design. An ICF-CY Checklist for Oral Health was completed with data from a structured interview with children 0-16 years old, referred for specialist dental health care, and their parents/carers. Additional information was retrieved from dental and medical records. Three groups were included in data analyses: one large international group of 218 children from Argentina, France, Ireland and Sweden; one large Swedish group with 99 children with complex disabilities; and one international group of children with disabilities and manifest dental caries from Argentina, France and Sweden.Results: The ICF-CY Checklist for Oral Health identified both common and varying functional, social and environmental aspects relevant for oral health and oral health care in children who had been referred to specialist dental clinics in four countries. Swedish children with caries experience had been referred to a paediatric dental specialist clinic at a significantly older age than caries-free children. The medical diagnoses were not significantly related to dental caries or child functioning in the large Swedish group with complex disabilities and low caries prevalence, nor was there a significant relationship between dental caries and child functioning. Collinearity between dental caries and problems in the functioning factor ’Interpersonal interactions andrelationships’ was observed in the international group of children with disabilities and manifest dental caries. DGA sessions with combined medical and dental treatment were common in the large Swedish study group. Children with experience of DGA had more severe problems in intellectual functions than those without experience of DGA. Problems in interpersonal interactions and relationships increased, while problems with mobility decreased, the likelihood for children having had experience of DGA. On international group level, dmft/DMFT was significantly higher in children with the experience of DGA than in those without DGA experience, but looking at Argentina, France and Sweden separately, this was not true for the Swedish children. There were significant, international differences between the prevalence of dmft/DMFT, DGA and environmental barriers.Conclusion: The biopsychosocial perspective, operationalised by the ICF-CY, contributes a holistic view on oral health and specialist dental health care in children with disabilities. In addition to certain differences, children with different health status from different countries share many functional and environmental aspects, important for oral health and dental health care. Early referral to a paediatric specialist dental clinic seemed favourable for oral health. The medical diagnosis was not related to child functioning or dental caries. Child functioning had a significant impact on DGA, and in children with disabilities and manifest dental caries, child functioning also had a correlation with caries. The dental caries burden was a stronger factor than functioning for the experience of DGA, however, dental health organisation and country context seemed to matter the most. Combining dental and medical procedures during the same GA session is good use of resources for both the individual and the society. To ensure children with complex disabilities to have the possibility of achieving equivalent good oral health as other children, DGA is one important factor.