Running head: ACCESS TO DENTAL CARE

Access to Dental Care for Mentally and Physically Challenge Populations Rochelle Betton-Ford Introduction to Research GRS 602-SB Master of Arts Leadership in Healthcare Professor Injic Siena Heights University

ACCESS TO DENTAL CARE

Statement of the Problem There are no visible signs or billboards denying access to dental care for persons with cognitive and physical challenges. Yet, access to adequate dental care for this group remains problematic. According to the Center for Disease Control 10 million Americans live with a developmental disability (Fisher, 2012). Senior citizens are living longer, with a third of persons age sixty-five and older being severely disabled (Steinberg, 2005). The number of persons with mental and physical disabilities will continue to grow each year. Dental professionals advocate bi-annual visits for preventive care for the general population. Why has the dental profession not embraced the mentally and physical disable populations, who are in dire need of these and routine services. Poor oral health and general health are interconnected especially diabetes, heart and lung disease (National Institutes of Health, 2011). This group continues to falls further behind the general population, increasing the risk for more invasive oral diseases. Dentistry is expensive, mentally or physically disable adults are often under or not insured. Medicaid may not provide dental insurance in all states for persons 21 years of age and older, regardless of a persons mental or physical disability. Another crisis facing America is the patient to provider ratio. Students are not applying to dental schools. Due to low reimbursement many dentist do not accept Medicaid. Thirdly, non-exposure of the special needs population to the public, people not accustom to the behavior of special needs means of communication. Schools have not properly prepared dental students to the special needs population. The

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government must actively advocate for this populations before they are viewed as aliens with no rights to adequate dental care.

Review of the Literature Multiple barriers to access to dental care for mentally and physically challenge populations have continued into the 21st century. Prior to deinstitutionalizing, dental services were provided more readily in a control environment. Patients were sedated and or physically contained in order to receive dental treatment in the institution proper (Burtner, Dicks, 1994) mandated by federal law. Forward to today, persons with cognitive developmental disabilities are now living with family members or in community group homes. Federal law requires patients be seen by a dentist annually (Solomowitz, 2009). One of the purposes for deinstitutionalized other than financial were to mainstream these individuals into society. How well mainstreaming is coming along is yet to be seen. Access to adequate dental care, has not been a successful transition, access is nearly impossible (Waldman, Perlman, 2002). There are multiple barriers to overcome; increase reimbursement to dentist for services provided, student debt. Patient to provider ratio attracting students to dentistry, public and dental care providers awareness and exposure to special needs population. Dental fear among persons with special needs to dentistry means to educate caregivers in providing home care. Creating polices from local and state government agencies to work on behalf of individuals with mental and physical disabilities.

ACCESS TO DENTAL CARE Poor oral health may result in physical changes associated with speech, digestive problems. Prescribed medications given in liquid form, is high is sugar, exposing teeth to an

increased risk of caries Fisher (2012). Persons with cognitive disabilities may have an additional health issues that must be taken into consideration prior to treatment. These considerations may be time consuming, and time is money, another reason dentist may chose not to service this population. Prevalence The populous of the United States have seen an increase in longevity, thanks to advancements in medicine, detection and diagnosis. There is also an increase in the number of persons with mentally and physical disabilities (Steinberg, 2005). Autism, cerebral palsy, Down syndrome, intellectual disability and physical disabilities are all under the umbrella of special needs. Preferred title; Intellectual disability hoping the stigma associated with the term mental retardation will be removed (NIDC, 2011). For the purpose of this paper a brief definition for persons with cognitive challenges are submitted; National institute of dental and Craniofacial Research (2011) briefly define intellectual disability intellectual disability is not a disease or a mental illness, it is a developmental disability that varies in severity and is usually associated with physical problems. According to Brave (2003) a persons inability to adapt to functional skills in self-care, health, safety and social skills. Degree of impairment ranges from profoundly impaired to borderline retardation. Children with intellectual disabilities are more visible in pediatric dental offices, and will routinely continue with the pediatric practice through adulthood. Familiarity with these patients makes dental appointments fairly easy; leaving the pediatric dentist may result in fear on the patients behalf and the new providers lack of exposure to special needs patient. Children may

ACCESS TO DENTAL CARE have insurance provided by parents, until they are 26 years of age, assuming parents have dental insurance other than government assistance. Medicaid provides dental insurance for children up to 20 years old, in most states. Limited procedures are available for adults receiving Medicaid, providing preventive treatment, and extractions. Patients with severe to profoundly cognitive and physical challenges and patients requiring more invasive procedures are usually referred to city or teaching hospitals for sedation, enabling multiple services in the least amount of time required. Additional barriers to dental care suggest referrals to hospitals may find locating a provider difficult, long waiting list, lack of transportation and the inability to afford treatment. Cost Barrier Possibly one of the greatest barriers to effective and adequate dental care for individuals

with intellectual disabilities is the inability and the lack of insurance coverage to pay for services. Many of these patients are insured through government assistance, such as Medicaid. Few states provide government assisted dental insurance for adults 21years and older, leaving the patient vulnerable for additional health issues associated with poor health. Furthermore, dentists are discouraged to service Medicaid recipients due to Medicaid low fee schedule (Waldman, Perlman, 2002). Overhead cost; salary, equipment, regulatory fees, administrative expenditures and the additional time and staff it takes to service mentally and physically challenge persons, are economically unpractical (Steinberg, 2005).

Under the Balanced Budget Act of 1997, cuts made to Medicaid and Medicare, provided coverage for only a few dental services considered cost-effective Steinberg, (2005). According to Steinberg (2005) policy dictates that the cost must be offset fully by reducing the hospitalization costs related to not providing the dental service. Under medical related circumstances Medicare

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will pay for dental care to address pathological and traumatic conditions, oral examination before kidney transplant, and extractions to prepare the jaw for radiation treatment (Steinberg, 2005). Further cuts by the Balanced Budget Act may eventually end dental coverage under Medicaid. Increasing the amount of monies payable to dentist for providing dental services will significantly increase the number of providers willing to adequately service these individual. Exposure Barrier According to the Centers for Disease Control ten million people have a developmental disability of in the United States (Fisher, 2012). Overall the general public has had little exposure to the special needs population. Rarely is a special need individual seen on television, the movies, or interact with them on the World Wide Web. Unfortunately the public continues to view special needs individuals as crazy, a retard, mentally sick and dangerous. Many are shunned by family members and starred down because of their limitations. Developing a curriculum in public schools may begin to educate students young people in understanding the difference and acceptance of those different from themselves. Dental students have little or no exposure personally or providing care for a special need individual while in school special Steinberg (2005). There has been a decrease in the amount of time treating and learning about the special needs patient in dental school compared to the 1960s and 1970s according to Doctor Bernick Steinberg (2005). A study to access dental students attitudes toward the care of individuals with intellectual disabilities, and changed attitudes including comfort zone prior to reviewing literature, concluded positive change in attitude towards these individuals (DeLucia, Davis, 2009). Dentist may not feel comfortable treating patients with intellectual disabilities, since they have limited exposure in school.

ACCESS TO DENTAL CARE The inability to understand the procedure and express themselves, can cause excitement exaggerate fear and anxiety in the dental office for a special needs patient (Gordon, Dionne,

Synder, 2008). Dental providers unaccustomed to behaviors of special needs patients may find it embarrassing and ill prepared in treating this population. Fear of patients leaving the practice due to behavior and the additional effort necessary to treat patients with intellectual disabilities, may be a deciding factor in not accepting these patients in their practice. Dental schools including dental hygiene programs, must incorporate a special needs course with substantial hours in the curriculum. Continuing education courses should also be made mandatory for all dental providers including support staff. Patient to Provider Ratio Number of students applying to dental schools and the number of students enrolling in dental schools have decrease from previous years; 1970 enrolled students to dental school 4,565 and 4,209 students in 1999. The reasons are not clear as to why enrollment is down, the annual tuition was13% higher than medical students in 2000, and is projected to increase over time (Waldman, H. B., Perlman, S. P., 2002). Consider the growing number of senior citizens requiring dental services and the growing population, indicating an imbalance patient to dentist ratio (Waldman, H. B., Perlman, S. P., 2002). There are fewer private practice establishments compared to twenty years ago. Student may seek employment with larger practices as employees until student debt is paid off. Not only is the need increasing in urban environments, there is also a need for dentist and dental providers in rural areas, individuals with developmental disabilities are less likely to receive dental care; add lack of transportation to the inability to pay for dental services and having Medicaid making this group a low priority. Provisions made by Healthcare reform may offer incentives attracting students to applying and

ACCESS TO DENTAL CARE enrolling in dental schools. Board of dentistry should feel inclined to develop a program for the Advanced Dental Hygienist with a Bachelor degree for consideration into the program. Similar to a Nurse Practitioner, additional 18 months to two years for advance license to provide operative services; simple restorations, simple extractions, pulpotomies- partial root canals, under indirect supervision. Oral Hygiene Persons with intellectual disabilities often have medical concerns as well as dental. Dental care is generally neglected until other issues are under control or resolved. Parents and caregivers, require additional instructions to help individuals maintain optimum oral health. Physical limitations either psychological or physical may impede normal brushing, rinsing and flossing. The inability for one to rinse or need to swallow and gagged (Fisher, K., 2012), properly manipulating a toothbrush, may seem impossible for persons with intellectual disabilities. Parent and caregivers will need to supervise the oral hygiene regimen. More and more person are placed in group homes by aging parents, behavior or for a number of reasons, oral care may lapse, therefore making it necessary to educate staff on the importance of regular and through homecare. Physician and nurses may offer assistance by providing literature and referring patients to a dentist as early as possible, this call for a collaboration between the two entities, requiring dental providers to agree to work with their medical counterparts. Alternative Treatment Patients with mild to some forms of moderate intellectual disability may be seen it a traditional setting requiring little treatment modifications (Solomowitz, B. H., 2009). Patients with severe to profoundly intellectual disabilities may fair better, preventing the patient from harming themselves or staff. All patients are candidates for intravenous sedation, evaluation of

ACCESS TO DENTAL CARE past and present medical histories all patient receiving care under sedation including intravenous sedation a dental clinic or outpatient setting. According to Solomowitz (2009) many group residencies are interested in providing the maximum treatment the fewest possible visits. Intravenous sedation requires less time, less trips for the patient and caregivers. Once again exposure to the mentally and physically challenge population is critical in the ability for dentist to properly prepare and execute a treatment plan of service for patients. Dental schools might focus on developing a specialty to treat persons with intellectual disabilities (Fisher, K. 2012). Conclusion

Access to dental care remains a problem, government agencies state and local levels must not only consider change in the way dental care is provided for persons with mental and physical challenges, but they must implement change for the long term. Medicaid is going through makeover a perhaps healthcare reform will make improvements to the system. Patients with intellectual disabilities are second citizen, do we live in a Utilitarian society, and only the strong survives? Dental schools have chosen not to spend more time than suggested to actively service this group or put in place a course for special needs. Allowing hygienist who are eager to service this group, is one alternative. Providing rotation assignments for dental students to render general and invasive dental services will begin to end the problem of access to care for mentally and physically challenge populations.

ACCESS TO DENTAL CARE References

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Brave, K., Brave, V. R. (2003). Dental and psychological approach in mentally retarded patients. Journal of Oral and Maxillofacial Pathology, 7(1) 19-20 Retrieved January 27, 2013 from http://www..jomfp.in/article.asp?issn=0973-00029X;year=2003;volume=7;issue=1 ;spage=19; Burtner, A. P., Dicks, J. L. (1994). Providing oral health care to individuals with severe Disabilities residing in the community: Alternative care delivery systems. Special care in Dentistry, 14(5) Retrieved March 08, 2013 from http://plaza.ufl.edu/burtner/provide. pdf DeLucia, L. M., Davis, E. L. (2009). Dental students attitudes toward the care of individuals With intellectual disabilities: Relationship between instruction and experience. Journal of Dental Education 73(4) 445-453 Retrieved March 08, 2013 from http://www.jdental ed.org/content/73/4/445.full.pdf Fisher, K. (2012). Is there anything to smile about? A review of oral care for individuals with intellectual and developmental disabilities. Nursing Research and Practice, 2012 Retrieved February 17, 2013 from doi:10.1155/2012/860692. Gordon, S. M., Dionne, R. A., Snyder, J. (2008). Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs. Special Care in Dentistry, 18, 88-92 Retrieved January 27, 2013 from doi:101111/J.1754-4505.1998.tb00910x NIDCR. (2011). Practical oral care for people with intellectual disability. National Institute of Dental and Craniofacial Research. Retrieved March 08, 2013 from http://www.nidcr.nih. Gov/OralHeallth/Topics/DevelopmentalDisabilities/PracticalOralCare. Solomowitz, B. H. (2009). Treatment of mentally disabled patients with intravenous sedation in

ACCESS TO DENTAL CARE References dental clinic outpatient setting. Dental Clinics of North America, 54(2), 231-242. doi: 10.1016/j.cden.2008.12.017 Steinberg, B. J. (2005). Issues and challenges in special care dentistry. Journal of Dental Education, 69(3), 323-324. Retrieved January 28, 2013 from http://www.jdentaled. org/content69/3/323.full Waldman, H. B., Perlman, S. P. (2002). Why is providing dental care to people with mental retardation and other developmental disabilities such a low priority? Public Health Reports, 117, 435-439. Retrieved February 06, 2013 from www.publichealthreports. org/issueopen.cf,?articleID=1191

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