Special programs for Special needs

As dental and dental hygiene school educators have recognized the need to prepare students for the care of the swelling geriatric population and its accompanying panorama of medical complications, so too must we develop innovative approaches to prepare our graduates for the care of special populations.

As dental and dental hygiene school educators have recognized the need to prepare students for the care of the swelling geriatric population and its accompanying panorama of medical complications, so too must we develop innovative approaches to prepare our graduates for the care of special populations.

by H. Barry Waldman, DDS, MPH, PhD; Cynthia C. Gadbury-Amyot, BSDH, MS, EdD; Sanford J. Fenton, DDS, MDS; and Steven P. Perlman, DDS, MScD

On July 30, 2004, the Commission on Dental Accreditation adopted a new standard for dental and dental hygiene programs to help prepare dental professionals to care for people with special health-care needs. The authors provide a review of the demographics of people with special needs, the limited dental educational opportunities to prepare students for the care of this population, how the accrediting standard was changed, and the difficulties involved in developing educational programs. Also, existing dental hygiene school programs are presented as examples that prepare graduates who want to help meet this need. Implementation of the revised standard is required by Jan. 1, 2006.

The key words in the new standard are accreditation, special needs patients, and developmental disabilities. The Commission states, “Graduates must be competent in assessing the treatment needs of patients with special needs.”

Special needs is 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 those individuals. These individuals include, but are not limited to, people with developmental disabilities, complex medical problems, and significant physical limitations.”1

Accreditation standards regarding the care of people with special needs have undergone a number of changes. By the end of the 1990s, Accreditation Standards for Schools of Dental Hygiene, Sections 2-18, Patient Care Competencies, stated, “Graduates must be competent in providing dental hygiene care for the child, adolescent, adult, geriatric, and medically compromised patient.” The “Statement of Intent” added, “An appropriate patient pool should be available to provide a wide scope of patient experiences that include children, adults, geriatric, and special populations.”1 Unfortunately, the term “special populations” is an all-encompassing phrase that does not specifically challenge dental hygiene schools to develop programs that prepare students to treat people with intellectual/developmental disabilities who seek care in private dental practices.

Numbers

More than 50 million U.S. residents have a developmental, physical, or mental disability that hinders them from functioning on their own or contributing fully to work, education, family, and community life.2 The 2000 Census indicates that:

• 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 that caused difficulty in learning, remembering, or concentrating.
• 6.8 million residents had a physical, mental, or emotional condition that caused 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.
• 21.3 million persons age 16 to 64 had a condition that affected their ability to work.3

Deinstitutionalization

For more than three decades, changing social policies, favorable legislation for people with disabilities, and class-action legal decisions that delineated the rights of individuals with intellectual/development disabilities have led to deinstitutionalization or mainstreaming - i.e., the establishment of community-oriented group residential settings - and the closing of many large, state-run facilities.

In the past, large state facilities offered a wide range of in-house health services provided by medical and dental professionals. Almost all of the current community residential facilities, however, are too small to provide in-house intramural services beyond the required annual examination.4 As a consequence, residents in community facilities depend on local practitioners for health services.

Student education

Since the mid 1950s, a number of schools have offered courses in the care of patients with special needs. These were designed to overcome dental professionals’ reluctance to treat these patients due to their lack of knowledge and experience in clinical management. However, by the end of the 1990s and currently, a series of studies found that during four years of education, more than half of U.S. dental schools provided fewer than five hours of classroom presentations and about 75 percent of the schools provided 0 to 5 percent of patient care time for the treatment of patients with special needs.5-7 In the most recent study, 50 percent of dental students reported no clinical training in the care of patients with special needs, and 75 percent reported little to no preparation in providing care to these patients.8

A national study of dental hygiene programs reported comparable findings:

• 48 percent of 170 programs had 10 hours or less of didactic training (including 14 percent with five hours or less)
• 57 percent of programs reported no clinical experience9

Bringing about change

Under the auspices of Special Olympics, it was proposed in 2001 that the Commission reestablish standards to ensure that dental and dental hygiene graduates are competent to provide oral health care to people with special needs.

Several national organizations including the American Dental Association, the American Academy of Developmental Medicine and Dentistry, and the American Dental Education Association requested that CODA revise its standards to ensure appropriate educational efforts to ensure the dental management of patients with special needs.10

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.

In 2002, CODA 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.

In 2004, lay and professional advocates instituted a major letter-writing effort, combined with personal contact. In July 2004, CODA adopted the accreditation standard “Graduates (of dental schools and schools of dental hygiene) must (sic) be competent in assessing the treatment needs of patients with special needs.”11

Realities

Dental educators are faced with significant economic difficulties that undermine efforts to expand programs preparing students to care for patients with special needs.

There are also limited numbers of trained dental and dental hygiene educators to provide the didactic and clinical educational programs for predoctoral students. Nevertheless, there are currently programs that offer direction for schools developing the needed educational programs.

Some examples of programs include:

• University of Missouri-Kansas City School of Dentistry, Division of Dental Hygiene - This program combines both classroom and clinical experience in working with special needs patients. The dental hygiene program is a 20 + 2 model, where students complete two years of prerequisites and finish their dental hygiene education at the School of Dentistry, with the award of a Bachelor of Science in Dental Hygiene. The curriculum consists of five semesters, with students beginning in the fall and going year round in order to graduate at the end of their second year.

Students are introduced to patients with special needs during the summer semester. The summer session consists of several clinic rotations in the community and within the school. Specific objectives have been developed and are carried out by the dental professionals and staff at each of the locations. Rotations include care in the Kansas City Regional Center for the Developmentally Disabled. Under the supervision of an attending dentist, the students provide dental hygiene care for children and adults with intellectual and physical disabilities. They also assess, plan, implement, and evaluate oral health-care services for a diverse geriatric population in area nursing homes. Another clinic rotation involves the Special Patient Care Clinic (SPCC) housed in the School of Dentistry. Each of these rotations continues throughout the student’s education.

Formal didactic instruction takes place during the fourth semester and includes emphasis on patients with special needs (oncology, gerontology, and physical disabilities), and managing emergencies in the dental office. Classroom presentations are provided by guest lecturers who have direct experience with or knowledge of special needs patients. Students are required to select from a variety of care practicums during their final semester, including one that involves the care of patients with special needs.

• Portland, Oregon, Community College (PCC) Dental Hygiene Program - This program uses a combination of classroom and clinic experiences to help students gain experience with special needs patients. PCC operates on a term/quarter semester system, and the program consists of six full-length terms and a five-week summer term, with the award of an Associate of Applied Science degree. During the third term, a didactic course introduces students to a variety of patients with special needs, including autistic and HIV patients.

Oregon enacted legislation in 1997 that allows for a “Limited Access” dental hygiene permit, or “LAP.” LAP dental hygienists may initiate services for patients in a variety of limited-access settings, such as extended-care facilities and facilities for people with intellectual and physical disabilities. Some lectures are provided by a LAP dental hygienist who works with patients in a limited-access setting.

Each student is required to see a patient with special needs and work with faculty to assess, plan, implement, and evaluate dental hygiene care. During their second year of school, each student must do a rotation to a community dental clinic that primarily serves HIV patients. PCC is a partner on a Ryan White Foundation Grant with Oregon Health Sciences University School of Dentistry, which provides students direct, supervised experience treating medically compromised patients, with special training in the physical, oral, and social problems encountered. (Personal communication, September 2004, J. Beach, instructor and clinic coordinator)

Solutions

There is no simple solution to prepare soon-to-be dental and dental hygiene practitioners with the acumen and willingness to provide oral health services for individuals with developmental disabilities. Yet millions of these people reside in our communities and are dependent upon the services of local practitioners for care. In many instances, these individuals are members of families who are currently being served by dental professionals.

Thus, as dental and dental hygiene school educators have recognized the need to prepare students for the care of the swelling geriatric population and its accompanying panorama of medical complications, so too must we develop innovative approaches to prepare our graduates for the care of special populations. We must meet the challenge of the Commission on Dental Accreditation that states, “Graduates must (sic) be competent in assessing the treatment needs of patients with special needs.”

H. Barry Waldman, DDS, MPH, PhD, is professor of dental health services in the Department of General Dentistry at SUNY at Stony Brook, N.Y. You may contact him at hwaldman@notes.cc.sunysb.edu. Cynthia C. Gadbury-Amyot, BSDH, MS, EdD, is professor and director in the Division of Dental Hygiene at the University of Missouri-Kansas City School of Dentistry. Sanford J. Fenton, DDS, MDS, is professor and chair in the Department of Pediatric Dentistry and Community Oral Health at the University of Tennessee College of Dentistry. He serves as director of dental services at the Crittenden Memorial Hospital in West Memphis, Ark. Steven P. Perlman, DDS, MScD, is global clinical director of Special Olympics, Special Smiles, and is associate clinical professor of pediatric dentistry at the Boston University Goldman School of Dental Medicine. He has a private pediatric dental practice in Lynn, Mass.

References
1 Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, July 30, 2004.
2 Agency for Healthcare Research and Quality. AHRQ Focus on Research: Fact sheet. Improving health care for Americans with disabilities. Web site: www.ahrq.gov/news/focus/focdisab.htm. Accessed March 17, 2004.
3 Waldrop J, Stern SM. Census Bureau. Disability status: 2000. Census 2000 Brief, March 2003. Web site: www.census.gov. Accessed March 18, 2004.
4 Dwyer RA. Access to quality dental care for persons with developmental disabilities. Chippewa Falls, Wisc.: Northern Wisconsin Center for Developmentally Disabled, 1998.
5 Fenton SJ. People with disabilities need more than lip services. Spec Care Dent 1999; 19(5):198-199.
6 Romer M, Dougherty N, Amores-Lafleur E. Predoctoral education in special care dentistry: paving the way to better access? J Dent Child 1999; 66(2):132-135-138.
7 Wolff AJ, Waldman HB, Milano M, Perlman SP. Dental students’ experiences with and attitudes toward people with mental retardation. J Amer Dent Assoc 2004; 135:353-357.
8 Cassamassimo PS, Seale, NS, Ruchs K. General practitioners’ perceptions of educational and treatment issues affecting access to care for children with health care needs. J Dent Educ 2004; 68(1)23-28.
9 Goodwin M, Hanlon L, Perlman SP. Dental hygiene curriculum study on care of developmentally disabled. Boston, Mass: Forsyth Dental Center, 1994.
10 Fenton SJ. If only we all cared. J Dent Educ 2004; 68(3)304-305.
11 Commission on Dental Accreditation. Accreditation Standard 2-26 for dental education programs. Adopted July 30, 2004.

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