BSTRACT Patients with developmental disabilities experience significantly higher rates of poor oral hygiene and tooth decay than their peers in the general population. Many factors contribute to the poor oral health and health inequity including access to dental care and dentists not being willing to treat patients with special needs. Increasing providers is one way to address lack of access, a far-reaching issue with public health relevance. Research has shown that the more confident and comfortable dentists are in treating patients with special needs, the more patients they will treat. Because confidence and comfort levels are directly correlated to quality of dental education regarding patients with special needs, dental schools have the ability to increase dental providers willing to see patients with special needs on a regular basis.
While all dental schools are required to instruct students about dental care for patients with special needs, high levels of variability exist in the number of hours students receive instruction as well as the type of experience (didactic, clinical, or community outreach). In order to better understand the factors that lead to new graduates seeing patients with special needs, a pilot program is necessary to establish what type of experience and how much of it is necessary to inspire graduates with enough confidence to treat patients with special needs. Surveys addressing dental education and recent graduates’ behavior in treating patients with special needs in their practice will serve as the initial step in addressing this concern. Data will confirm the relationship between education received and graduate behavior, elaborating and clarifying on a trend noticed in past research. By finding an area that directly impacts providers and access to care for the underserved population, adjustments can be made to this important public health problem.
As supported by the Surgeon General Report on Oral Health in 2000 and recent data from the National Health and Nutrition Examination Survey, dental caries is the most prevalent chronic disease in children (Evan and Kleinman, 2000). Using the National Health and Nutrition Examination Surveys, 42% of children ages 6-11 and 60% of children ages 12-19 had active dental decay (Dye et al., 2007). One population subset – Children with special health care needs (CSHCN) – have even higher levels of decay.
To address these concerns, the Department of Health and Human Services Healthy People 2020 includes many goals that are related to providing better health care for children with special health care needs. One goal, to “promote the health and well-being of people with disabilities”, recognizes that people with disabilities are more likely to not have an annual dental visit and experience difficulties in getting the health care they need (Healthy People 2020, 2011).
Preventing and controlling oral disease is also mentioned and specifically highlights the social determinants that affect oral health and the increase rates of disease in people with disabilities. In terms of “improving access to comprehensive, quality health care services”, HP2020 recognizes that limited access can lead to delays in receiving appropriate care, inability to receive preventive services, and increased number of hospital visits that could have been prevented (Healthy People 2020, 2011). While this objective does not specifically reference special health care needs, HP2020 does provide emphasis on increasing the number of children with primary care providers and insurance, two factors that have been shown to directly interact with health.
Despite the increased visibility and focus on this wide reaching problem, this health inequity continues today .As a group, CSHCN are more likely to have unmet dental needs and have higher risk of developing dental disease than typically developing children (Norwood et al., 2013). Some of the contributing factors for this disparity include frequent use of high-sugar containing medicine, dependence on a caregiver, reduced clearance of foods from the oral cavity, liquid or pureed diet, oral aversions, gingival overgrowth from medications, and medication associated xerostomia (Norwood et al., 2013). CSHCN who brush their teeth less than once a day or have poor oral hygiene had more new caries (59%) than their peers without special health care needs (Marshall et al., 2010). This leads to high oral disease risk for the 18% or 12.6 million children with special health care needs in the United States (Norwood et al., 2013).
Looking nationally, 64.7% of CSHCN are estimated to have teeth in excellent condition compared to 72.2% in non-CSHCN (Pennsylvania Disparities Snapshot, 2007). In Pennsylvania, the disparity gap widens with only 62.8% of CSHCN estimated to have teeth in excellent condition compared to 77.9% of non-CSHCN. Furthermore, 11.0% of CSHCN have had two or more oral health problems in the past six months compared to only 5.6% of non-CSHCN, resulting in more time away from school. One oral assessment conducted by US Special Olympics athletes in 20 states found that 12.9% of CSHCN reported dental pain, 39% demonstrated signs of gingival infection and nearly 25% had untreated decay (Satcher, 2000). In children without special health care needs, the percent of children with untreated dental caries is less than 14% (Satcher, 2000).
After reviewing the inequities that exist for oral health care, it is important to realize the impact poor dental health can have on systemic health. Supported by decades of research and stated by the Surgeon General in 2000, oral health is “essential to general health and the well-being of all Americans” (Evans and Kleinman, 2000). Poor oral health is associated with many diseases including heart disease, diabetes, stroke and pneumonia (Barnett, 2006). Oral health is also related to the well being and quality of life, diet, nutrition, sleep, psychological status, social interaction, school success, lost days of activity, restricted activity, and bed days (Evans and Kleinman, 2000). For children with special needs who are already at a disadvantage in these areas, layering on poor oral health will only increase the gap in health and achievement. For instance, children with existing special health care needs had three times as many bed days and school absence days as other children (Newacheck et al., 1998). Therefore, the oral health of this population directly influences the overall health disparities in children with special needs. Inequalities associated with children with special needs other than oral health include high dropout rates (14.8% compared to 3% in the state of Pennsylvania), higher poverty rates (25.9% compared to 8.3% in the state of Pennsylvania), higher death rates, and poorer health in general (Erickson et al., 2010).
Besides the increased risk for oral disease due to the behaviors mentioned above, there is also a disparity in access to dental clinics. In a survey of 208 practicing dentists, more than half (51.6%) did not treat any CSHCN in an average week (Dao et al., 2005). A questionnaire from 714 parents of CSHCN found that 35% of the respondents had difficulty finding dentists willing to treat their children (Al Agili et al., 2004). Significant barriers noted included only having Medicaid for dental insurance, starting with poor oral health, and a shortage of dentists with training in the care of CSHCN (Al Agili et al., 2004). Another study found that 40.9% of special need respondents said that cost was the significant barrier to going to the dentist (Gordon et al., 2008).Many CSHCN have Medicaid insurance for dental care but many dentists do not accept Medicaid insurance. For instance, in Pennsylvania (a state that already has a shortage of dentists), less than 25% of dentists will see Medicaid patients and less than 10% see CSHCN on a regular basis (ACHIEVA, 2009).Poor oral health also increases financial burden for these families. Compared to other children, CSHCN had three times the higher health care expenditures, including dental treatments (Newacheck and Kim, 2005). Families of CSHCN that experienced high out-of-pocket expenses were more likely to be from households with incomes below 200% of federal poverty level (Newacheck and Kim, 2005).
One of the areas where significant research has occurred regards education of dental students for treating CSHCN. In 2005, the Commission on Dental Accreditation set a new standard stating that “graduates must be competent in assessing the treatment needs of patients with special needs.” (Clemetson et al., 2012). As one might expect due to the vague requirement of “competent”, there is large variability with some dental schools requiring less than 5 hours of clinical exposure to CSHCN and only 29% of schools having a separate special patient care clinic. The majority of the training regarding CSHCN is occurring in pediatric dentistry specialty programs, a specialty with less than 5,000 members nationwide (Clemetson et al., 2012). The most commonly reported challenge from dental schools to increase exposure is curriculum overload (Krause et al., 2010). Most detrimentally, dentists do not feel prepared or competent at treating patients with various special needs (Karuse et al., 2010). In 2002, a survey of dental schools found that 41 percent of senior students well less than or not well enough prepared to provide care for patients with disabilities (Weaver et al., 2002). Studies have shown that students’ experience and education in providing oral health care to CSHCN is a key reason why they do not treat this population after graduation (Dao et al., 2005). General dentists report lack of confidence as well as financial difficulties, increased time needed, and physical access problems as the main reasons they will not treat children with special needs (Dao et al., 2005). However, in dentists who felt well prepared after dental school were both more likely to treat pediatric special needs patients and to provide services for patients with more diverse special needs than dentists who did not feel well prepared. Revision of curriculum standards has the potential to changing future providers feel about treating special needs patients but more evaluation is necessary.
As access to dental care for patients with special needs is a multifactorial problem with many variables involved, there are many areas at which to intervene. Due to the many children with special health care needs who have difficulty finding clinics where they can be treated, increasing the number of dental providers who are willing to see these patients is one approach. This paper suggests that by surveying dental schools and recent graduates of dental schools, a relationship between the amount and type of dental education regarding children with special health care needs with providers’ willingness to provide dental care to this population can be expanded and improved, and thereby helping to reduce the access gap that exists.