People with physical or mental disabilities, or with some neurodegenerative, neurological and psychiatric diseases, have specific needs when caring for their oral health and performing proper oral hygiene. 

There are almost four million people in Spain with some kind of disability (over one billion worldwide⁽¹⁾) of which 608.000 live alone, while about 1.39 million require assistance with their basic day-to-day activities⁽²⁾. 

People with special needs are those who, because of their illness, treatment, or physical or mental disorders, require special care. In the field of dentistry, such persons are known as “special patients”. 

These patients can be divided into the following groups by their condition⁽³⁾: 

• Physical disabilities (blindness, cerebral palsy, paraplegia ...).
• Mental disabilities (Down syndrome, autism ...).
• Neurodegenerative diseases (Parkinson's, Alzheimer's ...).
• Neurological and psychiatric disorders (epilepsy, schizophrenia ...). 

Special patients have anatomical, physiological, physical and psychological characteristics that must be taken into account when assessing their oral health. On one hand, these may affect the anatomy of the oral cavity; on the other, they may impair proper oral hygiene and thus lead to oral diseases such as dental caries (tooth decay) and gum disease, which are highly prevalent in these patients. 

Depending on the degree of disability, age, cooperation and systemic compromise, special patients may require care from others, as they may easily develop oral diseases that cause pain, dysfunction, discomfort and increased treatment costs⁽⁴⁾. 

However, it is important to note that there is no oral pathology that is exclusive to special patients. 

Toothbrushing 

It is recommended that all individuals take responsibility, to the extent possible, for their own oral hygiene. Brushing should be done for at least two minutes, without forgetting to brush all tooth surfaces. The use of brushes with small head sizes may be very effective for special patients (and for their caregivers if, due to their limitations, the individual cannot perform brushing correctly themselves) so as to access hard-to-reach points. 

It should also be noted that the handle of the brush should be adapted for use by special patients or, at least, should be easy to grip. Brushing technique is just as important as choosing a suitable brush. In patients with periodontal disease, the Bass technique is recommended. This involves placing the brush at the gumline at a 45-degree angle, making a slight to-and-fro motion at the gingival margin and sweeping towards the chewing surface. 

It is likely that due to their limitations, some patients will not have the skill necessary to perform this technique. In such cases, the horizontal scrub technique, which consists of a horizontal sweep of all tooth surfaces, is recommended. 

Electric toothbrushes can make brushing easier for special patients, as they help perform movements properly, ensuring brushing efficacy. 

The use of plaque revealers containing erythrosine dyes can be very useful for these patients in two ways: 

• Before cleaning, to show the areas where they must brush to remove plaque.
• After cleaning, to assess the effectiveness of brushing. 

Interproximal and lingual hygiene 

Interproximal hygiene should be performed daily, since interdental biofilm is the source of many oral diseases. The use of flexible interproximal brushes can help accommodate different angles. If the patient's constraints prevent this from being done correctly, there are interproximal brushes with longer handles to facilitate the task of the caregiver. If spaces are very tight, dental floss or tape should be used. To help with their use, there are floss spool dispensers and threaders that can make this task easier for both patients and caregivers. 

For these patients and/or their caregivers, oral irrigators are especially useful as they are easy to use and because they are highly effective in reducing plaque and gingival inflammation, especially between the teeth. 

Finally, it should be remembered that bacteria also collect on the tongue, particularly on the posterior dorsal surface, favouring the appearance of halitosis and acting as a reservoir for other oral infections. The tongue should therefore be cleaned daily with a tongue cleaner. 

Preventing decay, periodontal disease and halitosis 

As indicated above, periodontal disease is highly prevalent in special patients due to poor hygiene. The use of oral antiseptics in toothpaste and mouthwash is therefore highly recommended for prevention and control. 

Certain patients are not able to overcome the swallowing reflex and should therefore not use mouthwashes. Chlorhexidine spray (also for the treatment of small local infections or ulcers) or gauze soaked with chlorhexidine is particularly useful for these patients when further microbiological inhibition is required. 

Advice from the chemist 

The chemist's role is key in promoting good oral hygiene habits that will contribute to the prevention of oral problems. Specific, high-quality oral hygiene products may be recommended by the chemist, as well as advising good habits that help in maintaining proper oral health: a balanced diet and guidelines for oral hygiene (regular brushing, interdental hygiene). Patients and their families, as well as caregivers, should be made aware of the importance of good oral hygiene, the impact of inadequate care, and the need for regular check-ups by the dentist. 

Special patients often take medication for problems other than those associated with the mouth, although they may have an impact on it. There are more than 500 drugs (antidepressants, antipsychotics, anxiolytics, etc.) that may cause drying of the mouth (xerostomia), which in turn favours decay and periodontal disease, glossitis, halitosis, etc. Use by these patients of toothpastes and mouthwashes containing moisturisers or salivary stimulants is recommended. 

Prolonged use of medicines containing sugars may cause decay. Patients with greater risk of decay (poor hygiene, sugar-rich diets, prior history of decay) should use anti-decay (anti-caries) toothpastes and mouthwashes, which as well as containing fluoride, contain other active ingredients against decay, such as xylitol, or even some innovative formulations which, as well as the above components, include hydroxyapatite nanoparticles. 

Immunosuppressants such as cyclosporin, antihypertensives such as nifedipine (or other calcium channel blockers) and anticonvulsants (especially members of the hydantoin family) may cause gingival enlargement⁽³⁾. If this is the case, the dentist will be responsible for requesting consultation with the patient’s specialist to consider possibly changing his medication to avoid this side effect and, if this is not possible, to monitor the problem⁽⁵⁾. 

Dental trauma and tooth sensitivity 

Dental injuries are common among people with motor-coordination disorders, epilepsy or mental disorders (psychosis, dementia). In case of trauma where a tooth is lost, the caregiver should try to recover the tooth (if the root is intact, without touching it) and reposition it where possible, keeping it in place by having the patient bite on a napkin or handkerchief, and then go to a dentist urgently⁽⁶⁾. If this is not possible, the tooth should be kept in water, saline solution or milk to avoid dehydration until the dentist can be reached. 

In those patients with eating disorders (anorexia, bulimia), besides weight loss, it is common to see an increase in tooth sensitivity due to tooth erosion caused by vomiting. Products for sensitive teeth are recommended. These may also repair damaged enamel. 

Likewise, certain neurological disorders (such as bipolar disorder or psychosis) should not be ignored, as these may lead to self-inflicted harm by the patient anywhere on their body, including the tongue and oral tissues, etc.