Evolving realities of dental practice: care for patients with special needs.

When most dentists discuss changes in dental practice they tend to stress the impact of third-party insurance, new equipment, material and techniques. Some even emphasize the increase in the numbers of employees. For example, in the last 20 years the proportion of small dental offices (with fewer than five employees) decreased from 70% to 42% of all facilities. By 2002, almost 20% of dental offices had more than 10 employees. (1)

But profound changes also are occurring in dental practices throughout the entire country as increasing numbers of youngsters (and the not so young) with intellectual and developmental disabilities have become dependent upon local community practitioners for needed oral health services.

Numbers

Approximately 54 million people (about 20% of the population) currently live with some type of disability and this number is on the rise. More than 6 million residents in the United States (and nearly 200 million people throughout the world) have some form of intellectual disability. (2,3) Intellectual disability is more prevalent than deafness or blindness, and in most cases, is accompanied by secondary health conditions that place these individuals at greater risk for medical complications than the general population. "Access to appropriate health care for this population is often inadequate and generally of less quality than for the overall population." (4,5)

Results from the 2000 Census indicated that:

* 9.3 million residents had a sensory disability involving sight or hearing.

* 21.2 million persons had a condition limiting basic physical activities, such as walking, climbing steps or carrying things.

* 12.4 million individuals had a physical or emotional condition causing difficulty in learning, remembering or concentrating.

* 18.2 million individuals age 16 and over had a condition that made it difficult to go outside the home to shop or visit a doctor. (6)

The proportion of the population with sensory, physical and mental disabilities generally increases with age, reaching 40% or more for persons 65 years and over. Intellectual disabilities are the predominant disability among youngsters; physical disabilities predominate among the elderly.

In addition, there are variations by race/Hispanic origin and age in the proportion of the population with severe disabilities.

* Overall, a greater proportion of white and black non-Hispanic populations have severe disabilities, compared to Asian, Pacific Islanders and Hispanics.

* By age 65 and over, however, a greater proportion of minorities, compared to white non-Hispanics have severe disabilities (Table 1).

Changed residence

During the past 40 years, the number of individuals with intellectual and developmental disabilities in state institutions decreased from more than a quarter of a million to fewer than 42,000 persons in 2004. (7,8) Changing social policies, favorable legislation for people with disabilities, and class-action legal decisions have led to deinstitutionalization, the establishment of community-oriented group residences and family residential settings, and the closure of many state-run large facilities. In the past, health services were provided by state employees in these large facilities. But most community residential facilities are too small to provide services. As a consequence, individuals with intellectual disabilities are dependent upon community dental professionals for needed services.

Oral health needs

Although no national studies have been conducted to determine the prevalence of oral diseases among adult populations with specific disabilities, local and regional reports provide important information. These studies show that the population with intellectual and developmental disabilities has significantly higher rates of poor oral hygiene and periodontal treatment needs than the general population. There is a wide range of reported caries rates among people with disabilities, but overall their rates are higher than those of people without disabilities. (9) In the latest national study of children with special needs "the (health) service most commonly reported as needed but not received was dental care; more than 8% of (these) children needed but did not obtain this service." (10)

The reality is that repeated studies of the dental needs of individuals with intellectual disabilities indicate that about half "... had been refused dental treatment." (11) Almost two-thirds reported that it was difficult to find dentists willing to treat individuals with developmental disabilities. (10)

The education of the dental health team

An extended series of studies have found that in most dental auxiliary programs students received limited if any classroom and/or clinical opportunities to develop the background and experience to provide services for individuals with special health care needs. (12-14)

But all is about to change. As a result of an effort initiated under the auspices of Special Olympics, the Commission that accredits schools of dental education has adopted the standard, effective January 2006, that graduates of these programs "... must (sic) be competent in assessing the treatment needs of patients with special needs." (15)

Some suggestions

The fact is that in many instances the individuals with intellectual and developmental disabilities live in our communities and are members of families currently being treated in many dental practices. How well prepared is the dental practice in which you are employed to provide the needed services? Consider some of the following:

* Does your office have handicap access or does it need to purchase portable ramps?

* Do you feel comfortable or have you had experience transferring patients to the dental chair?

* Is the dental health team familiar with the oral health problems faced by people with disabilities?

* Does your office have mouth props or supportive devices to aid patients who may have difficulties in opening their mouths for treatment?

* Is the dental health team prepared to use behavior modification techniques that might be necessary to ensure proper treatment?

* Are you prepared to work with a variety of restorative materials that may be necessary to use because of disability-related issues?

* Is the dental health team knowledgeable about assistive devices to enable your patients to be more independent in managing their own oral hygiene?

* Are the practitioners (and you) familiar with being able to prescribe a personal oral hygiene program for an individual with intellectual/physical disabilities based on his or her level of understanding and ability?

There is no doubt that third-party insurance, new equipment, materials and techniques are transforming the practice of dentistry, but so too is the need to provide care to increasing numbers of individuals with special needs. Demanding? Yes. But essential and rewarding beyond words!

References

(1.) U.S. Census Bureau. County Business Patterns 1980; 2002. Washington, DC: Government Printing Office, 1982; 2004.

(2.) U.S. Department of Health and Human Services. Healthy People 2010: Disability and Secondary Condition, Chapter 6. Washington, DC: Government Printing Office, 2000.

(3.) Special Olympics. Promoting health for individuals with mental retardation--a critical journey barely begun. Washington, DC: Special Olympics Inc., 2001.

(4.) Kerr AM, McCulloch D, Oliver K, et al. Medical needs of people with intellectual disabilities require regular reassessment, and the provision of client- and care-held reports. Journal of Intellectual Disability Research 2003; 47:134-145.

(5.) Corbin SB, Malina K, Shepherd S. Olympics World Summer Games 2003--Healthy Athletes Screening Data. Washington, DC: Special Olympics, Inc, 2005.

(6.) Waldrop J, Stern SM. Census Bureau Brief, March 2003. Available from http://www.census.gov

(7.) Anderson LL, Lakin KC, Mangan TW, et al. State institutions: thirty years of depopulation and closure. Mental Retardation 1998;36:431-443.

(8.) Lakin KC, Braddock D, Smith G. Fiscal year 2004 institution populations, movement, and expenditures by state with national comparisons to earlier years. Mental Retardation. 2005; 43:149-151.

(9.) Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institutes of Health, 2000.

(10.) Department of Health and Human Services. The National Survey of Children with Special Health Care Needs: Chartbook 2001. Rockville, MD: Health Resources and Services Administration, 2004.

(11.) Dwyer R. Access to quality dental care for persons with developmental disabilities. 2000 Wisconsin State Legislature Special Committee on Dental Care Access Public Hearing. Available from http://www.legis.state.wi.us/ Ic/studies/DCA/dwyeraccess.pdf

(12.) Romer M, Dougherty N, Amores-Lafleur E. Predoctoral education in special care dentistry: paving the way to better access? Journal Dentistry for Children 1999;66:132-138.

(13.) Wolff AJ, Waldman HB, Milano M, et al. Dental students' experiences with and attitudes toward people with mental retardation. JADA 2004; 135:353-357.

(14.) Goodwin M, Hanlon L, Perlman SP. Dental hygiene curriculum study on care of developmentally disabled. Boston, Mass: Forsyth Dental Center, 1994.

(15.) Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, July 30, 2004.

H. Barry Waldman, DDS, MPH, PhD, is Distinguished Teaching Professor at the School of Dental Medicine, SUNY at Stony Brook, New York. He can be reached at [e-mail].

Steven P. Perlman, DDS, MScD, is Global Clinical Director, Special Olympics, Special Smiles. At The Boston University Goldman School of Dental Medicine he is Associate Clinical Professor of Pediatric Dentistry. Dr. Perlman has a private pediatric dental practice in Lynn, Massachusetts.