The Largest Minority Population With Unmet Oral Health Needs? Individuals With Disabilities
H. Barry Waldman, DDS, MPH, PhD; Steven P. Perlman, DDS, MScD, DHL (Hon); Allen Wong, DDS, EdD, DABSCD; Jack Dillenberg, DDS, MPH; and Rick Rader, MD, FAAID, FAADM, DHL (Hon)
More than 1 billion people-about 15% of the world's population-have some form of disability, of whom nearly 200 million experience considerable difficulties in functioning, according to the report on disability produced by the World Health Organization in 2020.1 In the years ahead, disability will be an even greater concern because its prevalence is on the rise. For example, in the United States, according to the Centers for Disease Prevention and Control, the number of children with autism spectrum disorder has increased to about 1 in 54 children.2 In addition, increases will occur as the population ages (people with disabilities also are living longer) and as a result of the higher risk of disability in older people.
Between 2016 and 2020, the proportion of the US population with disabilities increased by age from 5.4% for children to 50% for seniors aged 75 years or older. There are marked differences by race and ethnicity in the proportion of residents with disabilities: 6.9% for Asians, 7% for Hispanics, 9% for Whites, 14% for Blacks, and 16.6% for American Indians and Alaska Natives.3
People with disabilities generally have poorer health, lower education achievement, fewer economic opportunities, and higher rates of poverty than people without disabilities. This is largely because of the many obstacles they face in their everyday lives. People with disabilities develop the same health problems that affect the general population. Some may be more susceptible to developing chronic conditions because of the influence of behavioral risk factors such as increased physical inactivity. In addition, people with disabilities are more likely to be overweight or obese and to smoke. People with disabilities are at a greater risk of being a victim of violence than those without disabilities. The oral health of many people with disabilities is poor, and access to dental care is limited.
Lastly, many with disabilities are overlooked for dental caries risk assessment and management, resulting in increased health complications.
Barriers to Dental Care Service
The inability to pay for care remains the primary obstacle to obtaining oral healthcare for this population. Many people with disabilities lack private health insurance and are reliant on government programs, such as Medicare (which basically covers very few dental services) and Medicaid (which, in most states, does not cover dental services for adults), to pay for needed care. Other barriers include:
• language communication difficulties between individuals with disabilities and oral healthcare providers
• sensory impairments, eg, vision, hearing, and learning problems
• psychological issues, eg, low oral health literacy, dental anxiety, and past negative experiences
• limited transportation
• accessibility impediments, eg, dental offices that are not wheelchair accessible
• culture stigma and barriers: differing attitudes regarding the causes of disability and the treatment of the individual
Although many dental practitioners do provide care for the legions of patients with disabilities, it was not until 2004 that the Commission on Dental Accreditation (CODA) adopted a new standard that graduates of dental and dental hygiene schools must be competent in assessing the needs of patients with special needs. In subsequent years, the requirements were extended to include the preparation of care for these patients. Eventually, the American Dental Association modified the Code of Dental Ethics to specify that practitioners may not discriminate against individuals with disabilities.
However, there are barriers for current practitioners in preparing to provide care to individuals with disabilities, as many dental professionals graduated from dental schools prior to the implementation of the CODA requirements for the preparation of students to provide care for these individuals. Also, it may be difficult to find dentists who are trained and willing to treat children and adults with disabilities. Typically, the more significant the disability, the more difficult it is to find a dental professional who is prepared to provide the needed care. In addition, as noted earlier, limitations in insurance coverage, the restrictions of the Medicare and Medicaid programs, and the general lack of funding for state programs provide additional barriers to care.
Is Dentistry Prepared for Rise in Disability Rates?
The projected estimated proportion and number of individuals with severe disabilities are not available for 2030. A projection of 45.8 million residents with severe disabilities was developed by using US Census Bureau general total national population and state projects for the year 2030.
In 2015, the proportion of individuals with disabilities ranged from 9.9% in Utah to 19.4% in Puerto Rico. The estimated number of individuals with severe disabilities ranged from 71,000 in Wyoming to about 4.1 million in California. In 2030, the estimated number of residents with severe disabilities will range from 65,000 in North Dakota to nearly 4.4 million in California.
The question the authors propose is: Are individual practitioners, dental and dental hygiene schools, and the dental profession prepared to provide oral health necessities for the tens of millions of children and adults with disabilities as their numbers grow?
About the Authors
H. Barry Waldman, DDS, MPH, PhD
SUNY Distinguished Teaching Professor, School of Dental Medicine, Department of General Dentistry, Stony Brook University, Stony Brook, New York
Steven P. Perlman, DDS, MScD, DHL (Hon)
Global Clinical Director, Special Olympics, Special Smiles; Clinical Professor of Pediatric Dentistry, Boston University Goldman School of Dental Medicine,
Allen Wong, DDS, EdD, DABSCD
Global Clinical Advisor, Special Olympics, Special Smiles; Professor,
Department of Diagnostic Science, Arthur A. Dugoni School of Dentistry,
San Francisco, California
Jack Dillenberg, DDS, MPH
Mayor, Jerome, Arizona; Dean Emeritus, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona
Rick Rader, MD, FAAID, FAADM, DHL (Hon)
Director, Habilitation Center, Orange Grove Center; Member, National Council on Disability; President, American Association on Health and Disability
1. World Health Organization. Disability and health. WHO website. December 1, 2020. who.int/news-room/fact-sheets/detail/disability-and-health. Accessed July 20, 2021.
2. Autism Speaks. Autism statistics and facts. Autism Speaks website. autismspeaks.org/autism-statistics-asd#. Accessed July 20, 2021.
3. Ross M, Bateman N. Disability rates among working-age adults are shaped by race, place, and education. The Brookings Institution website. May 15, 2018. https://www.brookings.edu/blog/the-avenue/2018/05/15/disability-rates-among-working-age-adults-are-shaped-by-race-place-and-education/. Accessed July 20, 2021.