Table 2. The compilation of literature evidence regarding innovative approaches to maintaining oral hygiene in individuals with cerebral palsy (CP) and intellectual disabilities.

TQHPI - Turesky Quigley Hein plaque index, PI - plaque index, MGI - modified gingival index, SRP - scaling and root planing, GI - gingival index, VVIM - visual-verbal integration model, RCT - randomised controlled trials, NRS - non-randomised studies, ID - intellectual disability

AUTHOR and YEAR	TITLE	ORAL HYGIENE TOOL/ MODIFICATIONS	INFERENCE
Nour Asaad et al. 2022 [35]	Effectiveness of Apple Cider Vinegar and Mechanical Removal on Dental Plaque in CP patients.	Apple cider vinegar + SRP	In this research, the assessment focused on plaque buildup and gingival health using the TQHPI and MGI. Notable reduction in both indices in the apple cider vinegar group from the beginning of the study to the 6-month mark (p<0.05).
Burhanuddin Daeng Pasiga et al. 2020 [36]	Utilization of Special Grip Toothbrushes for CP patients.	Toothbrushes with specific handles	In this research, the focus was on assessing the dental hygiene status and the presence of halitosis in CP patients. A toothbrush specially crafted with a unique handle design made out of clay was employed. The distinct design of this toothbrush made it easier for individuals to effectively uphold their oral hygiene practices, leading to a reduction in bad breath.
Lakshmi Krishnan et al. 2019 [37]	Effectiveness of Two Different Modifications of Manual Toothbrush on Plaque Control in CP patients.	Toothbrushes with modified handle and head	In this study, adaptations were made to the standard toothbrush, encompassing changes to both its handle and head. The alterations made to the toothbrush involved using a 5mm ethaflex sheet to achieve the necessary thickness (corresponding to the child's hand grip circumference). The second adjustment included heating the brush with a hot air gun for 15 seconds, followed by angling it at 35˚-40˚ using a protractor at the shank. The alterations implemented on the toothbrush's handle resulted in a statistically notable variance in the PI. The manual brushing adjustments proved equally as efficient in removing plaque when juxtaposed with conventional brushing methods.
Husna Afifah et al. 2019 [38]	Effectiveness of wall-mounted automatic toothbrush against oral hygiene on CP patients.	Wall-mounted automatic toothbrush	In this study, modifications were introduced to the conventional toothbrush, encompassing alterations to both the brush's handle and head. Automated wall-mounted toothbrush systems feature a toothpaste dispenser for applying toothpaste to the brush and a water sprayer for rinsing after the completion of the tooth-brushing process. These adjustments applied to the toothbrush's handle yielded a statistically significant difference in the PI. The research demonstrated that these manual brushing modifications were just as proficient in removing plaque as the traditional brushing techniques.
Ni Zhou et al. 2019 [39]	Effectiveness of a visual-verbal integration model in training parents and their preschool children with intellectual and developmental disabilities to dispense a pea-sized amount of fluoridated toothpaste.	Visual-verbal integration model	This research centered on assessing the impact of visual-verbal integration models in coaching parents and their intellectually challenged children. The training utilizing visual-verbal integration models notably enhanced parents' proficiency in dispensing toothpaste. Moreover, children displaying greater adaptive skills experienced advantages from the VVIM training.
Catherine Waldron et al. 2019 [40]	Oral hygiene interventions for intellectual disabilities patients.	Various oral hygiene interventions (Cochrane study)	This study scrutinized the impacts, both positive and negative, of oral hygiene interventions, particularly the mechanical elimination of plaque, for ID patients. The research encompassed 19 RCTs and 15 NRSs comprising 1795 adults and children with ID along with 354 caregivers. Multiple approaches have been reviewed, encompassing distinctive manual and powered toothbrushes, oral hygiene education, monitored toothbrushing during programmed dental checkups, discussion using clinical photographs of plaque, different toothbrushing frequencies, plaque-disclosing agents, and personalized care strategies. The study found moderate-certainty evidence supporting only one conclusion: electric and manual toothbrushes are likely similarly effective in decreasing gum inflammation in people with ID over the mid-term. However, further comprehensive research is necessary to fully appraise interventions that display potential for enhancing oral hygiene among individuals with ID. It is crucial to confirm which interventions might be ineffective. Meanwhile, any amendments to current practices based on this review should be done with caution. Decisions about oral hygiene care should be based on professional expertise as well as the particular requirements and preferences of ID patients and their caregivers.
Trupthi Rai et al. 2018 [41]	Evaluation of the effectiveness of a custom-made toothbrush in maintaining oral hygiene in CP patients.	Customized toothbrushes	In this study, the effectiveness of personalized toothbrushes was compared to standard oral hygiene practices in preserving both dental and gum health in individuals with cerebral palsy. These personalized toothbrushes included features such as customized grip designs, elongated handles, electric toothbrushes with wider grip holders, and toothbrush heads designed with double or triple heads and longer shanks. Remarkably, the group using tailored toothbrushes displayed a notable reduction in percentages when examining the initial and final measurements for both the Plaque Index (PI) and the Modified Gingival Index (MGI).
Betty Saptiwi et al. 2018 [42]	The Impact of Irene's Donuts' Innovative School Program on Children with Special Needs Oral Health Care and Hygiene Index.	Oral hygiene maintenance program	In this study, the impact of ID’s Oral Health School Innovative Program on diminishing the risk of cavities in children with special needs was centered. This pioneering program emphasizes the significance of oral hygiene for both parents/caregivers and young patients. Clinical measures were documented before and after the behavioral program. A noticeable contrast in the Oral Hygiene Index Simplified (OHI-S) was observed before and after the behavioral program, demonstrating substantial enhancements particularly in parental/caregiver awareness regarding the importance of oral hygiene.
S M Kalf-Scholte et al. 2018 [43]	Plaque removal with triple-headed vs single-headed manual toothbrushes-a systematic review.	Triple-head vs conventional manual toothbrushes	In this research the efficiency of triple-headed versus single-headed manual toothbrushes in eliminating plaque is evaluated. The triple-headed toothbrush has three flexible and independent heads that cover the palatal (45-degree angle), buccal (45-degree angle), and occlusal surfaces attached to a single shank, ensuring comprehensive cleansing within that specific dental arch. Opting for a triple-head manual toothbrush, over conventional toothbrush, could be advantageous for plaque removal, especially when a caregiver is responsible for brushing a care-dependent individual.
Ana García-Carrillo et al. 2016 [44]	Use of Manual toothbrush vs sonic powered toothbrush in patients with intellectual disability: a cluster-RCT.	Sonic-powered or manual toothbrush	The efficacy of a sonic-powered or manual toothbrush in ID patients was evaluated in the context of PI and GI indices, alongside potential risks. The sonic-powered toothbrush validated was approximately as effective and safe as the manual toothbrush. In patients with mild to moderate ID, using powered or manual toothbrushes in conjunction with fluoride toothpaste might be beneficial to mitigate plaque and gingivitis.