The Lower Incisor Periodontal (LIP) Score: A Dental Screening Tool for Primary Care Physicians: Physicians Should Offer More Than "Lip Service" to the Oral Health Needs of Adults with Mental Retardation

Article excerpt

"Oral health is an integral part of total health. If you do not have good oral health, you are not healthy."

--Former Surgeon General C. Everett Koop

In spite of continuing scientific evidence linking periodontal disease to cardiovascular disease, low-birth-weight babies and other special conditions, physicians often ignore doing an oral exam as part of their routine physical examination. They rarely, if ever, concern themselves with oral conditions unless the patient presents with a specific complaint. As a matter of fact, when it comes to oral examinations, the universal term WNL (within normal limits) has come to mean "we never look."

A recent Surgeon General's Report on oral health (Oral Health in America: A Report of the Surgeon General, May 25, 2000) clearly demonstrates the overall poor oral health of Americans. As significant and comprehensive as this report was, it visibly lacked documentation of a significant population of individuals: people with special needs.

There are currently approximately 52 million Americans with disabilities, 7.5 million of those with mental retardation (MR). Individuals with MR have poorer overall oral health and oral hygiene than the general population, and there is evidence that these children and adults with special needs experience significant disparities in their access to quality dental services.

The reasons for this health disparity are complex and include lack of caregiver support, dentist reimbursement issues, genetic and other physiological disorders, medication toxicity, cultural and environmental factors, coexisting psychiatric or behavioral disorders and others.

While good epidemiological studies which demonstrate the incidence of periodontal disease in individuals with MR have not been done, there is evidence from screening studies during Special Olympics events that periodontal disease may be especially prevalent. In fact, the incidence of observable periodontal disease reported in the screening of thousands of children and adults according to standardized Centers of Disease Control protocols is 40 percent. As noted above, it is especially important to recognize and treat periodontal disease because, in addition to the oral health considerations, there is potential for medical systemic complications that can result from a chronic inflammatory process such as periodontitis. Thus there is evidence that chronic periodontal disease may be related to myocardial infarction, subacute bacterial endocarditis, cerebrovascular accidents, diabetes mellitus, chronic lung disease, autoimmune disorders and prematurity.

Therefore, we believe that strategies need to be developed that will lead to early detection and treatment of periodontal disease in persons with mental retardation.

One strategy that we and others have considered is that of better physician training, so that "gatekeeper" primary care physicians might be able to earlier detect and refer for appropriate treatment those oral health disorders encountered in their patients with mental retardation who might be at risk for periodontal disease.


Initially we developed a dental screening tool that physicians could easily understand and utilize. We called this the Lower Incisor Periodontal (LIP) score.

The lower incisors are inspected for calculus (dental plaque) accumulation and measured on a scale of zero to 4; zero represents no calculus, 1+ mild calculus, 2+ moderate calculus, 3+ severe calculus, and 4+ severe calculus with loss of teeth.


Sixty patients lived in a large state ICF/MR, while 41 patients resided in community-based group homes. All patients were referred to the "developmental disabilities" dentist because they demonstrated noncompliant, uncooperative behavior and could not be treated in routine outpatient dental clinics. …


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