In 2004, The Commission on Dental Accreditation adopted new standards for dental and dental hygiene education programs to ensure the preparation of practitioners to provide oral health services for persons with special health care needs. The course of action leading to the adoption of the new standards, together with the continuing obstacles of limited government support for dental services and the availability of faculty members to provide the needed dental educational experiences is reviewed. Expanding Health Resources and Services Administration definition of medically underserved areas is presented as one approach to improving the delivery of dental services.
In July 2004, the Commission on Dental Accreditation adopted new standards for dental and dental hygiene education programs to assure didactic and clinical opportunities to better prepare dental professionals for the care of persons with developmental disabilities, complex medical problems, significant physical limitations, and a vast array of other conditions that are considered under the rubric of “individuals with special needs.” Implementation of this revised standard was required by January 1, 2006. Specifically, patients with special needs has been defined as:
those patients whose medical, physical, psychological, or social situations make it necessary to modify normal dental routines in order to provide dental treatment for that individual. These individuals include, but are not limited to, people with developmental disabilities, complex medical problems, and significant physical limitations. (p. 15)
In a series of previous presentations in Mental Retardation, Waldman and colleagues detailed concerns of (a) whether physicians considered the dental needs of individuals with intellectual and other disabilities (Waldman, Perlman, & Swerdloff, 2001); (b) why providing dental services for people with disabilities is so difficult, with emphasis on the extremely limited preparation of dentists to provide needed care (Waldman & Perlman, 2002); and (c) the ongoing elimination of Medicaid dentistry for adults with intellectual disabilities (Waldman & Perlman, 2004). The following discussion highlights a successful step in the many paths needed to assure dental services for individuals with intellectual disabilities.
The Process for Change
A 3-year effort to bring about the needed change in the preparation of dental and dental hygiene school graduates was initiated by the authors under the auspices of Special Olympics. Accreditation standards, which originally required a variety of dental school didactic and clinic experiences in the “dental management of the handicapped,” were omitted when the Commission on Dental Accreditation (2001) adopted a competency-based format in the late 1990s. The adoption of the new standards was hardly a foregone conclusion as the initial steps were undertaken.
A series of national organizations, including the American Academy of Developmental Medicine and Dentistry, The ARC of the US, American Dental Education Association, American Academy of Pediatric Dentistry, Academy of Dentistry for Persons With Disabilities, and Special Care Dentistry joined the effort to request that the Commission on Dental Accreditation revise its standards to ensure appropriate educational efforts for the dental management of patients with special needs (Fenton, 2004).
The lack of adequate primary education for health care professionals to provide care to special needs populations was emphasized at the 2001 Surgeon General's Conference on Health Disparities and Mental Retardation (U.S. Pubic Health Service, 2002). In the most recent study, 50% of dental students reported no clinical training in the care of patients with special needs, and 75% reported little to no preparation in providing care for these patients (Wolff, Waldman, Milano, & Perlman, 2004).
In response, in 2002, the Commission on Dental Accreditation formed a committee to review its accreditation standards for dental and dental hygiene schools regarding clinical preparedness in the care of patients with developmental disabilities. Repeated proposals for change offered by the committee were defeated or tabled by the Commission's executive board.
In late 2002, the House of Delegates of the American Dental Association unanimously adopted a resolution to improve access to comprehensive dental services for persons with special health care needs.
In 2003, commissioners of the Commission on Dental Accreditation proposed revised standards to ensure competency of dental programs in the care of patients with special needs. Public hearings produced no negative testimony.
In 2004, a major letter writing effort, combined with personal contact, was instituted by lay and professional advocates (Waldman, Fenton, Perlman, & Cinotti, 2005). Finally, in July 2004, the Commission on Dental Accreditation adopted the accreditation standard that, “Graduates (of dental schools and school of dental hygiene) must be competent in assessing the treatment needs of patients with special needs” (boldface in original). But challenges remain.
Faculty and Funding
The reality is that there may be limited numbers of trained and prepared practitioners to provide the didactic and clinical programmatic support for the development of educational experiences for predoctoral dental students. Unfilled faculty positions continue as practitioners are unwilling to leave lucrative practices for teaching appointments with limited compensation, which in turn results from the precarious financial state of schools of dentistry. In addition, recent graduates are reluctant to pursue a full-time career because of their outstanding debt load and inadequate level of remuneration (Waldman et al., 2005).
Economics and the Special Case of Dentistry
“Families of children with special health care needs were best protected against inpatient hospital costs and most exposed to dental care expenses” (Newacheck & Kim, 2005, p. 10).
The frequent reporting that there are between 40 and 45 million individuals in the United States who have no health insurance, together with the associated health and economic consequences, fills government reports, publications of the health professions, the printed media, and the evening news (Denavas-Walt, Proctor, & Mills, 2004). The fact that approximately 15% of the population has no health insurance is in itself grave; almost beyond comprehension when we consider the extent of private insurance arrangements and government programs. Even more significant, however, is the reality that despite some recent decreases in the proportion of the population without health insurance, the use of a single national summary figure masks and understates the true magnitude and variability of the numbers and proportion of children and adults who lack total or particular components of necessary coverage. For example,
From January through June 2003, 42.3 million persons of all ages (14.8%) were uninsured at the time of interview, 52 million (18.2%) were uninsured for at least part of the past year, and 27.7 million (9.7%) were uninsured for more than a year at the time of interview. (Cohen & Ni, 2004, p. 1)
While 44 million Americans lack medical insurance, about 108 million lack dental insurance (National Institute of Dental and Craniofacial Research, 2000, p. 1).
Children with disabilities are aging out of dental care …(because) most states (using selective coverage) provide minimal if any dental services for adults within the Medicaid system. (Waldman & Perlman, 1997, p. 389)
In 2003, virtually half of expenditures for dental services were covered by private insurance arrangements; essentially tied with physician services for the greatest share of costs covered by private third party insurers. Once again, however, 108 million individuals lack dental insurance (National Institute, 2000).
As a result, 44% of dental service costs were paid out-of-pocket; a far greater proportion than all other major health services. Specifically, 3% of hospital care costs, 10% of physician services costs, 25% of nursing home and home health care costs, and 35% of prescription drugs costs, were paid out-of-pocket (see Table 1).
The reality is that government spending for dental services has been particularly limited. Since 1980 (with projections through 2011), the government's proportion of spending for overall personal health services (including federal, state, and local agencies) ranges from 39% to 44%. During this period, government spending represents between approximately 53% and 60% of all hospital service costs, 30% and 35% for physician services, 11% and 23% for prescription drug costs, and 49% and 64% for nursing home costs. By contrast, government spending for dental services ranged from 2.9% in 1990 to 5.6% in 2001, with projections that it will reach 7.3% in 2011 (Heffler et al., 2002).
For children with special health care needs:
Nearly 13 percent of U.S. children have special heath care needs, and 20 percent of U.S. households with children have at least one CSHCN [children with special health care needs] who require care and services beyond those of most children …[and] lack of insurance was the strongest indicator for delayed or foregone care; 11.8 percent …were uninsured for at least part of the 12 months prior to the survey. (Health Resources, 2005, p. 1)
Compared with other children in 2000, children with special health care needs had three times higher health care expenditures ($2,099 vs. $628). “The 15.6% of CSHCN [children with special health care needs] accounted for …33.6% of total health care costs (including dental costs) attributed to children in 2000” (Newacheck & Kim, 2005, p. 1). Nationally, there is a gradual progressive increase with age in the proportion of children with special health needs who have no health insurance. In addition, there are marked variations by demographic characteristics in the proportion of children without health insurance. Among children with special health care needs, compared to the general population, the proportion with no health insurance was (a) double the rate for Hispanic children, (b) 4.5 times the rate for children in families where the interviews were carried out in Spanish (or other than English languages), (c) 4 to 5 times the rate for children in lower income families, and (d) almost 9 times the rate for children in families with maternal level of education of 8th grade or less.
Slightly more than one in five children had public insurance (primarily, Medicaid) coverage (Blumberg, Osborn, Luke, Olson, & Frankel, 2004). Unfortunately, “after years of enduring Medicaid's shortcoming, many dentists are washing their hands entirely of the program” (Schlossberg, 2004, p. 12). Most important, however, because of the limitations of adult Medicaid dental services in many states, children once eligible for dental services under the Early and Periodic Screening, Diagnostic and Treatment program “age out” of dental care when they reach 21 years of age (Waldman & Perlman, 1997).
The Next Step in Advocacy
The litany of the panorama of the obstacles that challenge individuals with intellectual and other developmental disabilities, who increasingly reside in community and family residencies, has filled any number of journal articles and individual patient care histories. In this example, the intensive efforts by a series of concerned individuals and organizations resulted in an essential step to assure the preparation of dental and dental hygiene practitioners to provide the needed care.
This same group of advocators is now approaching the Health Resources and Services Administration in an effort to have individuals with intellectual and developmental disabilities included in Health Resources and Services Administration's (2005b) definition of medically underserved populations (i.e., currently, the definition is based on the ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over.
In an effort to meet operating costs of dental schools, the price for a 4-year dental education at some private schools has reached the range of a quarter of a million dollars. In past years, dental school financial difficulties were exacerbated by the federal government's elimination of Graduate Medical Education funds for dental school sponsored general practice and specialty education programs. In 2002, student education debts for almost three of five dental school graduates were in excess of $100,000 (Weaver, Haden, & Valachovic, 2002). The extension of the definition of medically underserved populations would offer the incentive of loan forgiveness (and grants) for dental (and medical) practitioners to provide services to individuals with intellectual and developmental disabilities.
Paraphrasing the findings of a national study on the expenditures for children with special health care needs, health policy changes that would extend the breath and depth of care are needed to ensure that individuals with special health care needs are protected against the burden of inadequate health services (Newacheck & Kim, 2005). The adoption of new standards for the education of dental and dental hygiene practitioners to prepare them to care for individuals with special needs may be but one step. But good news is always welcome!
Authors: H. Barry Waldman, DDS (firstname.lastname@example.org), Distinguished Teaching Professor, Department of General Dentistry, SUNY at Stony Brook, Stony Brook, NY 11794–8706. Steven P. Perlman, DDS, Global Clinical Director, Special Olympics, Special Smiles; Associate Clinical Professor, Pediatric Dentistry, Boston University Goldman School of Dental Medicine, 100 E Newton St., Boston, MA 02118