Frustration: Educating Dental Professionals to Provide Care to People with Special Needs

More than 50 million United States residents have a developmental, physical, or mental disability that hinders their ability to function on their own or contribute fully to work, education, family, and community life.¹ About 17% of US children under 18 years have a developmental disability. In 2000, US births included the following²:

• 12,500 children with cerebral palsy,
• 5,000 children with hearing loss,
• 4,400 children with vision impairment,
• 5,000 children with heart malformations,
• 5,500 children with other circulatory/respiratory anomalies,
• 800 children with spina bifida/meningocele,
• 3,300 children with cleft lip/palate, and
• 8,600 children with a variety of musculoskeletal/integumental anomalies.

Approximately 2% of school-age children have a serious developmental disability such as mental retardation or cerebral palsy and need special education services or supportive care.³

Results from the 2000 census indicated the following⁴:

• 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 stairs, reaching, lifting, or carrying;
• 12.4 million individuals had a physical, mental, or emotional condition causing difficulty in learning, remembering, or concentrating;
• 6.8 million residents had a physical, mental, or emotional condition causing difficulty dressing, bathing, or getting around inside the home;
• 18.2 million individuals age 16 and older had a condition that made it difficult to go outside the home to shop or visit a doctor; and
• 21.3 million persons age 16 to 64 had a condition that affected their ability to work.

DEINSTITUTIONALIZATION
In 1967, there were more than a quarter of a million individuals with mental retar­dation/developmental disabilities (MR/DD) in state institutions. For more than 3 decades, changing social policies, favorable legislation for people with disabilities, and class-action legal decisions that delineated the rights of individuals with MR/DD have led to deinstitutionalization (“mainstreaming,” ie, establishment of community-oriented group residences and enhanced personal family residential settings) and closure of many state-run large facilities. For example, in 1977, approximately 54,100 child and youth residents with mental retardation were in large state facilities. By 2000, the number of these younger residents in the 189 facilities had decreased to 2,100 individuals. The total number of individuals of all ages in these facilities had decreased from 151,100 (in the mid 1970s) to 47,300 by the beginning of the new century.^5,6

DENTAL STUDENT EDUCATION
Since the mid 1950s, a number of dental schools have introduced instruction in the care of patients with special needs. These efforts were made to overcome dentists’ reluctance to treat these patients because of their lack of knowledge and experience in clinical management.⁵ However, by the end of the 1990s and into the present century, a series of studies have found that during the 4 years of education, more than half of US dental schools provided fewer than 5 hours of classroom presentations, and about 75% of the schools provide from zero to 5% of patient care time for the treatment of patients with special needs.^5-9 In the most recent study, 50% of the students reported no clinical training in care of patients with special needs, and 75% reported little to no preparation in providing care to these patients.¹⁰

In addition, a national study of dental hygiene programs reported comparable findings¹²:

• 48% of 170 programs had 10 hours or less of didactic training (including 14% with 5 hours or less); and
• 57% of programs reported no clinical experience.

The inadequacies in the preparation of dental school and dental hygiene school graduates have been demonstrated repeatedly during the didactic and clinical training programs that the Special Smiles component of Special Olympics has carried out throughout the United States for more than 10 years (unpublished data, Special Olympics, 2003).

TRYING TO BRING ABOUT CHANGE
The Commission on Dental Accreditation (CODA), in cooperation with the ADA, provides overall control to ensure the educational programs of dental and dental hygiene schools meet accepted standards.

• In 2001, under the auspices of Special Olympics, it was proposed that CODA re-establish standards that had been deleted in the mid 1990s that ensured dental hygiene and dental school graduates were competent in providing oral healthcare to individuals with special needs.
• A series of national organizations in­cluding the American Academy of Develop­mental Medicine and Dentistry, American Dental Education Association, American Academy of Pediatric Dentistry, Academy of Dentistry for Persons with Disabilities, and Special Care Dentistry have requested that CODA revise its standards to secure appropriate educational efforts to ensure the dental management of patients with special needs.¹³
• The lack of adequate primary education for healthcare professionals to provide care to special needs populations was emphasized at the 2001 Surgeon General’s Con­ference on Health Dispa­rities and Mental Retar­dation.
• In 2002, CODA formed a committee to review its dental and dental hygiene schools accreditation standards regarding clinical preparedness in the care of patients with developmental disabilities. Committee recommendations were tabled at a later CODA meeting. A new committee was formed to review the recommendations of the first committee.
• In late 2002, the ADA House of Delegates unanimously adopted a resolution to improve access to comprehensive dental services for persons with special healthcare needs.
• In 2003, CODA commissioners 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, CODA again tabled a vote on proposed changes. A new committee was formed to present proposals for change.

The next meeting to consider changes is scheduled tentatively for mid 2004.

DIRECTIONS
Dental educators are faced with a series of significant difficulties, which can undermine efforts to expand their programs to provide students with meaningful opportunities to prepare them to care for patients with special needs.

Economics

• 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 the past year, 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 3 out of 5 dental school graduates were in excess of $100,000.¹⁴

Faculty
Unfilled faculty positions continue as practitioners are unwilling to leave successful practices for teaching ap­pointments with limited compensation, which in turn results from the precarious fi­nancial state of schools of dentistry. Recent graduates are reluctant to pursue a full-time career because of their outstanding debt load and inadequate level of remuneration.

• The support and coordination by CODA to establish standards that ensure dental students are educated in providing care to people with special needs; and
• Continued groundswell and support by institutions and individuals to ensure the needs of healthcare for children and adults with special needs.

We may be frustrated—but we have not given up!

References

1. Agency for Healthcare Research and Quality. AHRQ focus on research: improving health care for Americans with disabilities. Available at: http://www.ahrq.gov/news/focus/focdisab.htm. Accessed March 17, 2004.
2. Honeycutt A, Dunlap L, Chen H, et al. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment – United States, 2003. MMWR. 2004;53(03):57-59.
3. National Center for Birth Defects and Developmental Disabilities. Develop­mental disabilities. Available at: http://www.cdc.gov/ncbddd/dd/default.htm. Accessed March 17, 2004.
4. Waldrop J, Stern SM. Disability status: 2000 – census 2000 brief, March 2003. Available at: http://www.census.gov/prod/2003pubs/c2kbr-17.pdf. Accessed March 18, 2004.
5. Waldman HB, Perlman SP. Preparing to meet the dental needs of individuals with disabilities. J Dent Educ. 2002;66(1):82-85.
6. Fenton SJ. Survey of training in the treatment of persons with disabilities. InterFace. 1993;9:1,4.
7. Goodwin M, Hanlon L, Perlman SP. Dental Hygiene Curriculum Study on Care of Developmentally Disabled. Boston, Mass: Forsyth Dental Center; 1994.
8. Fenton SJ. Universal access: are we ready? Spec Care Dentist. 1993;13:94.
9. Fenton SJ. People with disabilities need more than lip service [editorial]. Spec Care Dentist. 1999;19(5):198-199.
10. Romer M, Dougherty N, Amores-Lafleur E. Predoctoral education in special care dentistry: paving the way to better access? ASDC J Dent Child. 1999;66(2):132-135.
11. Wolff AJ, Waldman HB, Milano M, et al. Dental students’ experiences with and attitudes toward people with mental retardation. J Am Dent Assoc. 2004;135:353-357.
12. Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ. 2004;68(1):23-28.
13. Fenton SJ. If only we all cared. J Dent Educ. 2004;68(3):304-305.
14. Weaver RG, Haden NK, Valachovic RW; American Dental Education Association. Annual ADEA survey of dental school seniors: 2002 graduating class. J Dent Educ. 2002;66(12):1388-1404.

Dr. Waldman is professor of dental health services, department of general dentistry, SUNY at Stony Brook, NY. He can be reached at (631) 632-8883 or hwaldman@notes.cc.sunysb.edu.

Dr. Fenton is professor and chairman, department of pediatric dentistry and community oral health, University of Tennessee College of Dentistry, and director of dental services, Crittenden Memorial Hospital in West Memphis, Ark. He can be reached at (901) 448-6206 or sfenton@utmem.edu.

Dr. Perlman is global clinical director, Special Olympics, Special Smiles, and associate clinical professor of pediatric dentistry, The Boston University Goldman School of Dental Medicine. He maintains a private pediatric dentistry practice in Lynn, Mass. He can be reached at (781) 599-2901 or sperlman@bu.edu.