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Inside Dentistry
February 2009
Volume 5, Issue 2

Serving Patients with Special Needs

Allison M. DiMatteo, BA, MPS

Patients with special needs are defined as “those patients with medical, physical, psychological, or social situations that 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.”1,2 This population of patients is reported to have higher rates of poor hygiene and, as a result, a greater incidence of gingivitis and periodontitis, as well as caries, than members of the general population.

According to Albert H. Guay, DMD, chief policy advisor for the American Dental Association, the subject of “special needs” patients in dentistry is a complicated one. Before beginning a specific conversation on the topic, a better term than “special needs” is required.

“It’s such a broad basket of conditions that are covered by the term special needs that it doesn’t say very much and, on the other hand, it sometimes says far more than it means to say,” Guay suggests. “We have a definitional problem that makes the discussion of the subject more difficult.”

“Special needs” patients could encompass the multitude of patients who are elderly or suffering with mobility issues and/or both. Those who cannot travel to a dental office “must have dental personnel provide dental care to them where they reside. There are a variety of barriers to access for this group, including lack of facilities, insufficient reimbursement, complicated administration, poor daily support from care-givers, and lack of experience among dental personnel.”3

“I have a problem with the stereotyping of ‘special needs’ patients because in the process, I think what we do sometimes is reinforce a negativity or an anxiety on the part of dentists regarding ‘special needs’ patients,” explains Larry Coffee, DDS, executive director of the National Foundation of Dentistry for the Handicapped (NFDH). “I think that does a serious disservice to all kinds of mentally, physically, and medically disabled individuals and others who would perhaps fall within one’s perception of ‘special needs’ patients.”

“You could easily say that ‘special needs’ patients are everybody with a disability that is defined in the Americans with Disabilities Act. In dentistry, when you look at the different dental hygiene books that include chapters about special needs, then it’s really interesting,” observes Marita Rohr Inglehart, Dr. phil habil, a professor in the department of periodontics and oral medicine at the School of Dentistry at the University of Michigan, Ann Arbor. “Some say that pregnant women are special needs patients. There is a lot of ambiguity about the term ‘special needs patients’ among dentists and dental hygienists.”

The dental-patient population with “special needs” also includes patients who are immunocompromised or have cardiovascular disease, diabetes, bleeding disorders, and any number of other systemic conditions that can affect how their oral healthcare needs are addressed. According to David A. Reznik, DDS, director of the Oral Health Center at the Grady Health System in Atlanta, Georgia, there is a greater number of people in the United States today living with immunosuppression than ever before, for a multitude of reasons.

“Special needs” patients also encompass those individuals who are mentally ill and the nature of whose illness makes it difficult for them to maintain proper dental hygiene, let alone seek out and maintain dental care, and whose medications can compromise their oral condition (ie, contribute to xerostomia, caries, etc).4 For these patients, dental treatment can involve ensuring good oral care, but this typically requires a caregiver or case manager, keeping appointments short, and scheduling appointments when there is relative psychiatric balance.4

Other “special needs” patients are those who are mentally challenged, intellectually disabled, or otherwise disabled individuals who may need to be accompanied to dental appointments, whose disabilities may include an inability to comprehend a need for dental hygiene or treatment, and/or who may have missing or discolored teeth.4 Such patients can typically be treated in general dental practices with the assistance of family and/or care providers. Some procedures may require the use of anesthesia or sedation for the rare patients who are severely disabled.

Inside Dentistry this month turns its focus to defining exactly what the conversation should be about when discussing “special needs” patients and their dental care. The emphasis, as we’re told, is warranted, since part of the problem of access, finances, and reluctance to provide care is a misunderstanding about who these patients are, as well as what their special needs entail.

Compassion and Understanding Start with Education

It has been argued and hoped that increased didactic and clinical opportunities for new dental school and dental hygiene program graduates to provide services to individuals with special needs would prepare increasing numbers of practitioners to treat this needy segment of the patient pool.2 However, it needs to be clear exactly what these patients’ needs are, and what is needed and expected of practitioners who provide their dental care.

Barbara J. Steinberg, DDS, a clinical professor of surgery at Drexel University College of Medicine, suggests that caring for patients with special needs should be introduced at the undergraduate level. After that, most of the training could be achieved in a residency program in the student’s fifth year, whether it is in a school-based residency program or a hospital-based program, which is something that Steinberg strongly advocates.

“The better you prepare future dentists and future dental hygienists to provide care for patients with special needs during their education, the more comfortable they actually will be once they are out there in practice treating patients, and the more likely they will be to provide care to these patients,” explains Inglehart. “A wonderful change in the accreditation standards for dentists and dental hygiene programs states that the graduating dental students and the graduating dental hygiene students must be prepared to diagnose the needs of ‘special needs’ patients. That is the first step in the right direction, because it basically requires all the programs now to explicitly prepare their students for the diagnosis of ‘special needs’ patients.”

In fact, the change to which Inglehart is referring involves the accrediting process for dental schools and dental hygiene schools that took effect in January 2006. According to H. Barry Waldman, DDS, MPH, PhD, a distinguished teaching professor in the School of Dental Medicine at Stony Brook University, the new accreditation requirement is designed to provide an educational experience for students in the care of people with special needs. Waldman explains that according to CODA standards, every dental school and dental hygiene school that comes up for re-accreditation must have a program to teach/train students in the care of patients with special needs such that “...graduates must be competent in assessing the treatment needs of patients with special needs.”

“What has occurred is that maybe in the past there was an adequate attempt to prepare the practitioners to care for ‘special needs’ patients, but now it’s a requirement for the accrediting of the institution, and this is going to change things,” Waldman explains. “Now schools are providing didactic and clinical experiences for the up-and-coming graduates of the school.”

Some clinicians working with disabled patients suggest that most “special needs” patients with mild to moderate disabilities can be treated by general dentists. However, with little experience in handling these patients, a fear of how to manage their needs and how other office patients might react becomes “a pivotal factor in whether care is provided at all.”5

“If you’re exposed to patients with special needs during your dental education or during your postgraduate education, then willingness to treat these patients when in practice increases,” explains Reznik. “There are people who are emotionally invested and buy into care for patients with special needs because they might have a parent with Alzheimer’s, or a family member who has a need for radiation and chemotherapy who, therefore, has to have their dental issues addressed pretty quickly.”

Waldman believes that there needs to be an ongoing continuing education program for practitioners to assist them in the process of getting to know what is meant by “special needs” patients and what the indications for their treatment might be. While most continuing education programs are offered at exotic locations and focus on one of two subject areas (eg, how to manage the office to facilitate operations and increase net income; and technique-oriented education ranging from implants to esthetic restorations), Waldman advocates programs that foster an appreciation of the kinds of conditions that fall into the realm of “special needs,” the range of physical/mental disabilities within those categories, and how clinicians can address such patients’ dental care.

“For example, you’re talking about the patient who may not be able to sit still for an extended period of time. How do you manage that kind of patient?” Waldman says. “I think that this type of continuing education also has to do with eliminating the fear that dentists have when they hear that someone is “not perfect” or going to be the perfect patient, whatever that means.”

The Reality of Treating Patients with Special Needs in the General Practice

Guay points out that currently 75% to 80% of dentists are in general practice, leaving only 20% to 25% in specialty practice. Of those, Guay says only a small percentage are trained to treat what he terms “very difficult ‘special needs’ patients.”

“So, these patients have to be treated in the general dental office or they won’t get treated,” Guay says. “There just are not enough dentists with specialized skills or experience to treat that population, because they’re not concentrated in one place such that one practitioner can provide care to everybody.”

However, Guay emphasizes that with the proper orientation, attitude, and interest, a general practitioner can treat many of the individuals who are classified as “special needs” patients. Not all “special needs” dental patients are severely disabled, he says.

“A great many patients with special needs can be treated by general practitioners if the dentists look upon their treatment in a systematic way, and if they’re not fearful or scared away by a preconceived notion that they conjure up in their own minds based on how a patient is labeled,” Guay believes.

Steinberg says that it’s very difficult to say that there are absolute special skills required to treat “special needs” patients. Rather, she says everything [eg, knowledge, specific treatment approaches] comes with experience in treating this patient population.

“Everything has to be on an individual basis because everybody’s needs are different, whether it’s a medical situation that’s complicating the dental treatment, or it’s the patient’s mental situation or they’re physically handicapped,” Steinberg explains. “All of these factors will color how the dentist is going to treat that patient on an individual basis.”

Guay notes that in cases involving children with Down syndrome, there is a great range of inabilities of such patients, from the point of being able to be treated in the general dental office like any other patient, to those who are very difficult to treat. So, by having this label, the dentist shouldn’t assume right away that he or she is going to have the worst case scenario coming to the practice, he says. Rather, the clinicians should first find out about the patient and not be afraid to undertake the initial treatment visit. From there, the dentist should be able to determine his or her ability to provide treatment and comfort level in doing so.

In cases involving patients with severe disabilities, specialized equipment and general anesthesia might be required, in which case the average general practitioner would not be equipped to provide care within the ordinary office routine, Guay says. There may be a point beyond which the dentist doesn’t feel capable or comfortable in providing treatment, and he or she should realize what that point is and refer those patients elsewhere.

Coffee acknowledges that there are going to be individuals who are more profoundly and severely disabled, but that these patients represent a relatively small percentage of the total developmentally disabled population. There are going to be some, a relatively small number, who will need pharmacological management in order to receive their dental care, he adds, noting that there will be even fewer who will require hospitalization for general anesthesia in order to receive their treatment.

“But I think that in the majority of cases, general dentists are going to be pretty comfortable providing competent care for the majority of patients who are labeled as special needs,” Guay says. “Then, after providing care for these types of patients for some time, dentists should be prepared. In other words, there may be things you need to do a little differently to treat some of these patients with special needs, and that’s important.”

Making Dental Treatment of Patients with Special Needs a Reality

According to Reznik, there needs to be an emphasis on education about medical conditions within the dental profession when it comes to treating patients with special needs. He explains that many times, his colleagues around the country will be hesitant to take a “special needs” patient, whether it is a brittle diabetic or someone with a medically complex condition.

“Once the medical issues they need to be aware of have been explained, much of that hesitancy goes away,” Reznik has observed. “So I think we need to emphasize education.”

According to Inglehart, there is a need for dental practitioners to understand a “special needs” patient’s condition in a bottom-up manner (ie, what the illness, condition or disability is), as well as in terms of a top-down approach (ie, how does the dentist and the staff/practice modify its routine and/or environment to match or accommodate the patient and his/her needs). In this regard, there is a great deal of ignorance among practitioners regarding a variety of conditions, she says. She emphasizes the need to read the literature to develop an understanding of the patient’s condition and/or disability, as well as how to match the practice environment to the patient in order to provide optimal care.

“With autism, for example, we know that patients with autism are very aversive to any kind of change and any difference in relation,” Inglehart explains. “So, dental practitioners must now think about how they can set up the environment in such a way that when the autistic patient comes in, he or she experiences exactly the same environment every time, the same care, the same person that provides care, even the same outfit that the person wears.”

Reznik notes that people are living longer and presenting with complex diseases that could place them in the “special needs” category. Today’s dentists must be able to focus on the medical part of the profession, such as reading complete blood counts and understanding what the values mean, for example, in the context of treating a diabetic. This sometimes gets lost in the shuffle to keep up with technological advances, such as those associated with new equipment, new materials, and new ways of doing things, he suggests.

“Many people are afraid of medically compromised patients, and the reality is that many dentists already have the skills to treat them, but they’re concerned about a comfort level that they don’t have,” observes Janet Yellowitz, DMD, MPH, president of the Special Care Dentistry Association. “So, for example, it’s not that providing dental care to older adults or medically compromised individuals requires a new set of dental skills. It’s really dealing with their medical management and compromised health status, or with the limitations of what they can do on a daily basis. I think there is just a tremendous fear factor that stops people from treating these patients.”

Reznik also emphasizes the need to have dental benefits/reimbursement sources. Many people who have special needs are also disabled and would qualify for Medicare, yet Medicare doesn’t have a dental benefit, he says. There is no financial incentive for dental treatment, and many of these patients are without options.

“We need to increase access, and to accomplish this, there needs to be a reimbursement source,” Reznik explains.

Yellowitz says that for many patients, trying to pay for dental treatment can be a pretty dismal situation. If they are medically indigent and don’t have funds, they can’t afford care, she says. Further, if they live in a state where there isn’t medical assistance for older adults, then the resources are very limited, she says.

“For many people, there are just no resources to assist them in getting the care that they need, and many don’t even know that they need care,” Yellowitz explains. “Many older adults are unaware that they need dental care on a routine basis, and they’re waiting for the pain to present. Generally, when the pain presents, it’s late in the disease process, and the treatment options are much more limited and often much more extreme.”

According to Coffee, for the vast majority of individuals who his organization (eg, NFDH) is endeavoring to assist (ie, mentally, physically, and medically disabled individuals of all ages), he says that the most serious problem they face relative to accessing dental care is the inability to pay for it. Many are only marginally employed or unemployed because of their conditions.

That doesn’t mean that they are going to be difficult to manage in terms of dental treatment, Coffee explains. “Special needs” patients may be unable to maintain full-time employment, and they therefore may be exceedingly vulnerable because they personally cannot afford the care they need, and the government programs on which they are dependent do not provide the coverage.

“There are clearly more problems to deal with than just money, but relatively speaking, there is no barrier to accessing care for vulnerable populations that is more pervasive, more common, more serious, and seemingly more unmanageable than their financial inability to access care,” Coffee emphasizes.

The National Foundation of Dentistry for the Handicapped

According to Rob Saldaña, director of the DentaCheques program for the National Foundation of Dentistry for the Handicapped (NFDH), the organization operates with a core budget of about $1.5 million, but the yearly care provided to between approximately 7,000 and 7,300 individuals is valued in excess of $16 to $17 million a year and approaches $18.5 million. That figure is all-inclusive, reflective of the value of the donated materials from laboratories, the time and expertise given by the dentists, and the value of such materials as implants.

“However, there is never enough money,” Saldaña explains.

For this reason, the NFDH began last summer to study the feasibility of launching a major fundraising campaign beyond its annual fundraising activities, explains Gary D. Schrenk, MNM, CFRE, director of development for the NFDH. The purpose of the ambitious campaign would be to create a $20 million endowment fund sufficient to cover the organization’s basic operating costs for perpetuity.

“In the short term, until the endowment is in place, we will also be soliciting increased funding to allow NFDH to bring its programs up to scale to better meet existing and emerging dental needs of our constituents,” Schrenk says, noting that the NFDH raises nearly $3.8 million annually from foundations, corporations, individuals, state funding, and the DentaCheques earned-income coupon book. “At any given time there are between 15,000 and 20,000 people on the NFDH’s Donated Dental Services (DDS) waiting lists. These are real people with real needs located throughout the country that must have help, but there are not enough volunteer dentists to take them on as patients.”

Increased funding to the NFDH will allow for expanded recruitment of volunteer dentists, but subsequently require the number of DDS coordinators also to be increased to provide case management to the larger numbers of patients who will be served, as well as coordination of a growing volunteer corps, Schrenk explains. He adds that the creation of strategies to provide preventative education concerning the specialized dental needs of those who suffer from chronic diseases also is needed and is currently under study. In addition, NFDH is hoping to help those whose financial resources are depleted by the costs of dealing with chronic illness to obtain the dental care they require, as well as explore ways to assist those who need organ transplants to get the dental care required prior to receiving their donated organ, he says.

Special Care Dentistry Association and the Society for Geriatric Dentistry—Focusing on Specific Needs and Treatment Challenges

The Special Care Dentistry Association (SCDA) is an international organization uniting three groups of oral health professionals: the American Association of Hospital Dentists (AAHD), the Academy of Dentistry for Persons with Disabilities (ADPD), and the American Society for Geriatric Dentistry (ASGD). According to SCDA president Janet Yellowitz, DMD, MPH, because the three groups had commonalities in what each was doing in terms of service, education, and goals/activities, they fully integrated several years ago to better serve members and the patients they treat.

The SCDA has close to 1,000 members comprised of dentists, dental hygienists, and dental assistants, as well as nondental healthcare providers, health program administrators, residents, students, and hospitals. A wide range of “special needs” patients of all ages are represented, with a primary focus on individuals with physical disabilities, hospital patients, and geriatric patients. Members are provided with support, education, and training through a variety of avenues, including continuing education programs at the SCDA annual meeting (to be held in Baltimore in April), a regularly distributed newsletter, and The Special Care in Dentistry Journal, which is published six times a year.

“The annual meeting addresses a continuing education program geared toward clinical activities and some policy issues, as well as what we can do to make changes,” Yellowitz says. “We also make ourselves available to people if they contact the office and need assistance directly.”

The ASGD and SCDA provide a forum for the exchange of ideas—what works, what doesn’t work, materials, trends, opportunities—that is unparalleled, says Alan M. Stark, DDS, PhD, president of the ASGD. Members have the ability to share perspectives with likeminded practitioners from across the country, and in fact North America, and recognize that they don’t have to face their challenges alone.

“The group is small enough that you are likely to be able to speak to lecturers and have access to those individuals that you come to seek out,” Stark says. “But we’re also large enough to attract national authorities. It’s really a nice place to be.”

Caring for Aging Dental Patients
Geriatric dentistry represents a very interesting, very dynamic field right now, observes Stark. The influence that the retirement of the baby-boom population will have on society at large and on the financial health of dental practitioners in the future is going to be significant, he says.

“If practitioners recognize this powerful trend and prepare themselves to treat this rapidly growing demographic segment, they will be more successful sooner, more satisfied professionally, and more integrated into the communities in which they live, as well as have elevated rates of satisfaction in all aspects of their professional career,” Stark outlines. “This is a very substantial trend.”

Paramount to successfully treating this cohort of patients is recognizing the diverse and numerous potential challenges with which aging patients may present. By and large, this is a complex group of individuals who age at different rates, Stark says.

“We tend to look at age as a chronological phenomenon and, certainly, it is. But with regard to dental care, we need to also factor in the biologic age and the ability of patients to accommodate to insults along with aging,” Stark explains. “There is a difference between patients who are aging in health and those who are aging with illness.”

Patients who are aging in health express some predictable trends, such as a decrease in pain sensitivity when they reach approximately age 70. Practitioners need to recognize that this group of patients often will not come to the dental office and present with acute distress, even if they have issues that are acute dental issues, Stark says. Oftentimes, these patients present with confounding kinds of symptoms, such as food packing in and around a tooth because part of the tooth is broken away.

Those patients who age with illness age with a host of other issues, such as organ system issues (eg, heart, liver, kidney, lung) or blood issues. Oftentimes, these patients take multiple medications prescribed by multiple physicians, Stark has observed. With these patients, dentists need to look for issues regarding cognition and the ability to give informed consent, since decisions can be clouded by systemic disease and made even more complex by the medicines used to manage the systemic disease, he says.

When proving care to aging patients—or discussing this patient population—Stark indicates that modifying the language used when referring to these individuals is important. He has stopped referring to them as geriatrics and now uses the term “aging patients,” noting that he receives a more positive reaction from continuing education course participations. He suspects that practitioners don’t want to treat geriatric patients, but that they already have aging patients in their practice whose special needs they want to understand.

Other to-do items include brightening the lighting in the practice so it’s not too dim; redesigning forms so that the font size is large enough for aging eyes to read; and providing chairs in the reception room that have arms on both sides so that patients with orthopedic issues can sit down comfortably and get up comfortably.

As far as managing the specific dental implications of aging, one of the most important things is recognizing xerostomia, Stark says. Most dentists are very comfortable with the objective signs of xerostomia and look for thick, ropy or frothy saliva. The other component to evaluating patients’ xerostomia is subjective, Stark emphasizes.

He notes that many times he has examined the mouths of patients taking diuretics, which are a first-line medicine for dealing with hypertension that causes dry mouth, only to find that the mouth appears to be well hydrated, even with saliva on the floor of the mouth. However, upon asking the patient if their mouth feels dry, he says he’s amazed at the number of people who say yes.

“It’s important to look at the whole person—at their chronologic age, their biologic age, inside their mouth at the teeth and periodontal structures—in the context of overall health,” Stark says. “Doing so will provide practitioners with a wealth of insight as to how they want to continue providing care to these individuals.”

Readying Yourself and the Practice for Patients with Special Needs
According to Larry Coffee, DDS, executive director of the National Foundation of Dentistry for the Handicapped, the greatest disability that disabled individuals—or otherwise “special needs” patients—share is an extraordinary dependency on the benevolence of others. Applying that to dental care, there is a harsh and tragic truth that dental professionals need to be aware of, which is that for reasons beyond any of their control, these individuals, with an array of disabilities, have an extraordinary dependency on others for their oral health, he says.

“They are not going to be difficult patients to treat. They’re going to be very appreciative and grateful patients to take care of,” Coffee says. “They are dependent upon the benevolence, the understanding, and the compassion of those of us who have been spared the same kinds of problems that they have.”

It has been Coffee’s experience that the majority of the 13,500 volunteer dentists, most of whom are general practitioners, in the NFDH’s largest program—called Donated Dental Services—feel comfortable taking care of the vast majority of people that the organization refers to them for care. It’s a very small number of “special needs” patients who, after being seen by the general dentist for the first time, will need to be referred to a specialist, Coffee explains.

“The technical aspects, the actual something called dentistry—whether it’s fillings, extractions, dentures, bridgework, or esthetics—dentists know how to do. This is not something that’s brand new,” explains H. Barry Waldman, DDS. “It’s just that now you’re coming at it with a different approach. We’re talking about an opportunity for the dentist to have a more in-depth understanding of the patient and what his or her various disabilities and limitations are.”

In fact, Waldman emphasizes that dentists have two very important skills that they implement every day in order to be successful. They develop interpersonal relationships with their patients and they manage their patients.

“A surgeon puts you to sleep and then doesn’t have to talk to you. But dentists treat patients. They interact with their staff. They interact with their patients, and this is a commodity that they have, in a sense, to be successful,” Waldman notes. “Dentists have this ability, and it’s the interrelationship of knowing your patients, who they are, and what they need that keeps them in practice.”

To prepare yourself and your staff to treat “special needs” patients, there are several things you can do to ensure a successful and comfortable experience for everyone.

Get as much training, experience and exposure to treating “special needs” patients as possible. Education in the care of patients with special needs for dental practitioers—whether dentists, hygienists, or assistants—is available in continuing education forums, says Barbara J. Steinberg, DDS. Regional and state meetings offer hands-on type programs to train members of the dental team in treating these patients.

Janet Yellowitz, DMD, MPH, stresses that there are skills that clinicians can learn, be they management skills or patient behavior management skills. Some people know them intuitively while others need to be walked through them, she says, but they’re all learnable.

“Not everybody has to treat aging patients, and not everybody has to treat patients with disabilities, but we certainly have to beef up our practitioners to be prepared to do so because we’re not ready for the patient populations that are yet to come,” Yellowitz says. “You have to look at the patient’s needs.”

In the general practice, start slowly. Albert H. Guay, DMD, urges clinicians not to schedule a whole day just for “special needs” patients. Rather, many patients with special needs could fit into the regular practice schedule, even though their care may require more time.

Be an advocate for dental services for people with special needs, Guay says. Go out to those people who receive agency funding for care, or help provide transportation for patients with special needs.

“One of the main issues why we see so many dentists not willing to treat these kinds of patients is that there hasn’t been the financial remuneration available for dentists to treat them,” Steinberg observes. “Medicaid and Medicare have been very deficient in covering the dental needs of patients with special needs, and private insurance companies don’t take into consideration the amount of time required of the dentist and other members of the staff to treat these patients.”

Know your patient. Steinberg says that while some special skills may be required to provide care, the most important aspect of caring for a “special needs” patient is getting to know the entity that you’re dealing with. “Then, you have to sit down with your team and see how you can best provide care in light of the patient’s situation,” Steinberg says.

For example, if you will be treating older patients, recognize that these individuals often have problems with sensitivity to glare. Their dental chairs should not be set up so they’re looking out the windows, explains Inglehart. Additionally, some older patients may have a hard time hearing if music is playing in the background, so that must be considered when older patients are being cared for, she suggests.

Encourage a team approach to care. According to Guay, this may involve someone, such as an extra assistant or hygienist, or a person the patient trusts who can relay information and facilitate communication, if necessary, so that things go smoothly.

Work efficiently during procedures. Unfortunately, some patients with special needs may have just as low a tolerance for long dental procedures as people without special needs. Therefore, assembling an efficiently coordinated dental team and planning the procedures for a visit ahead of time will help to ensure a comfortable visit, Guay suggests.

Take cues from caregivers. According to Inglehart, a study of the caregivers of adult, independent living patients (ie, mostly developmentally delayed) demonstrated that those caregivers know very well how to ensure that a patient cooperates during dental treatment. It showed that caregivers are a valuable resource in treating patients with special needs, since they can instruct dental staff in what to do and what not to do when they behavior manage a patient, Inglehart says.

“Just listening to those caregivers could potentially make a big difference. For example, a challenging child we treated would always come in after school and, after talking with the mother, it was learned that his medication for ADHD—which he receives in the morning—was wearing off, which is why he was giving us a harder time,” Inglehart recalls. “At that point, we scheduled the child for first thing in the morning, and his appointments went smoothly thereafter.”

The Inside Look from...

Issue after issue, the feature presentations in Inside Dentistry deliver coverage of the relevant and thought-provoking topics affecting the greater oral healthcare profession at large. The publishers and staff could not bring the underlying concerns and trends surrounding these timely issues to the forefront without the insights shared by our knowledgeable and well-respected interviewees. For their collective generosity of time and perspectives, we extend our sincere gratitude.


According to Rob Saldaña, director of the DentaCheques program for the National Foundation of Dentistry for the Handicapped (NFDH), what are needed to reduce the disparities in oral health status and access between patients with special needs and those without special needs are awareness and a connection. He recalls hearing about a dentist who was in church and heard a friend mention knowing of someone—a deserving, good person who couldn’t earn a living due to his or her special needs—who couldn’t afford their dental care, after which the dentist was willing to help provide care for that individual.

“If more dentists knew about the need and took it on a personal level—one that wasn’t asking them to change the world, but to just change one life, that alone would make a difference,” Saldaña believes. “There are more than 150,000 dentists in this country, and if each one helped one person, that would be a start.”

However, Reznik notes that as the population gets older, dentistry will see more people living with reduced mental capacity who will need assistance, and dental professionals will have to learn how to manage different patient populations. What’s more, they will have to do so not just in a medically appropriate manner, but to a degree, in a culturally competent, age-appropriate manner, also, he says.

“We need to treat people as if they’re people,” Reznik emphasizes. “Sometimes we look at people or our patients as just patients, and it really has to be based on humanity, their needs, and what dentistry can do for them.”

With that being said, Guay cautions against the current rush toward cost containment and minimizing the time that practitioners spend with each individual patient due to time and financial constraints that can ultimately lead to a breakdown in the doctor/patient relationship. He stresses that dental practitioners need to be strong advocates for patients with special needs so that this patient population will not be left behind.

“Care for these individuals is going to cost more, and it will take more time,” Guay says. “You cannot apply the ‘rules’ of efficient practice when dealing with many of the patients with special needs. It would be very easy for them to get lost in the shuffle.”

About the Contributors

Larry Coffee, DDS
Executive Director
National Foundation of Dentistry for the Handicapped
Denver, Colorado

Albert H. Guay, DMD
Chief Policy Advisor
American Dental Association
Wakefield, Massachusetts

Marita Rohr Inglehart, Dr. phil. habil.
Department of Periodontics and Oral Medicine
School of Dentistry
University of Michigan
Ann Arbor, Michigan

David A. Reznik, DDS
Director, Oral Health Center, Infectious Disease Program
Chief, Dental Service
Grady Health System
Atlanta, Georgia

Rob Saldaña
Director, DentaCheques
National Foundation of Dentistry for the Handicapped
Denver, Colorado

Gary D. Schrenk, MNM, CFRE
Director of Development
National Foundation of Dentistry for the Handicapped
Denver, Colorado

Alan M. Stark, DDS, PhD
President, American Society for Geriatric Dentistry
Kornberg School of Dentistry, Temple University
Department of Oral and Maxillofacial Pathology, Medicine and Surgery
Philadelphia, Pennsylvania

Barbara J. Steinberg, DDS
Clinical Professor of Surgery
Drexel University College of Medicine
Philadelphia, Pennsylvania

H. Barry Waldman, DDS, MPH, PhD
Distinguished Teaching Professor
School of Dental Medicine
Stony Brook University
Stony Brook, New York

Janet Yellowitz, DMD, MPH
President, Special Care Dentistry Association
Department of Health Promotion and Policy
University of Maryland
College Park, Maryland


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