BARRIERS TO DENTAL CARE ACCESS

ARTICLE ABSTRACT Background: The number of adults with developmental and acquired disabilities is growing and there are not enough general dentists treating special needs patients to meet the increased demand. In Oakland County, there are 140,160 persons registered with a developmental or acquired disability and only 36 dentists in the county that are indicated for treating patients with special needs. Methods: A survey was sent to 385 students, ages 3 to 26, at six special education schools and developmental centers in Oakland County. There were 117 responses. Results: The most difficult barrier to oral healthcare that adult patients with special needs, encounter is finding a dentist willing to treat these complex patients. 20% of the surveyed population currently does not have a dentist. There is a correlation between decreased dental access and lower median income. Conclusions: There is a significant need for improving special care dentistry training and increasing the number of general dentists that are able and willing to treat adults with special needs. Adequate resources and a database can help caregivers, parents, and medical professionals locate dentists who treat special needs patients. Increased ­experience for general dentists through residency training and continuing ­education courses will help to increase confidence and knowledge in practice special care dentistry.

KEY WORDS: dental education, oral health, developmentally disabled

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Barriers to dental care access for patients with special needs in an ­affluent metropolitan community Julie J. Williams, DMD;1* Craig C. Spangler, DDS;2 Nisha K. Yusaf, DDS3 1General

Practice Resident; 2Program Director; 3Associate Program Director, General Practice Residency, St. Joseph Mercy Oakland, Pontiac, Michigan. *Corresponding author e-mail: [email protected] Spec Care Dentist 35(4): 190-196, 2015

Int r od uct ion

In any major metropolitan area, it is reasonable to expect that patients should have at least some access to necessary dental care. While there are numerous dentists actively marketing and seeking patients, for adults with congenital and developmental disabilities, this may not be the case. In the State of Michigan, the greater Detroit area is composed of three counties. One of these counties, Oakland County is the second most affluent county in Michigan. Within Oakland County, there are 42 h ­ ospitals, 882 ­general dentists, and 180 dental specialists for a population of 1.2 m ­ illion people.1–3 Yet, only 36 dentists have voluntarily indicated that they are willing to treat special needs patients.4 In Oakland County, there are 140,000 people over 5 years of age who have been identified as “disabled” by government agencies.5 The number of adults with disabilities has shown to be increasing nationally. Trends show this will only continue as life expectancy of special needs patients improves, with over 90% living past the age of 20 years old.6 Persons with special needs have higher unmet dental needs, in comparison to the general population.7 How does this apparent shortage affect the ability of patients with special needs to find dental treatment, and what other barriers exist? It is recognized that adults with special needs have unique challenges when seeking preventative and restorative dental treatment. Complex physical and medical conditions, along with behavioral challenges, can make diagnosis and treatment difficult. This also makes the role parents or caregivers have, in providing daily preventive care, more difficult. In addition to these factors, general dentists who are interested in treating special needs patients may lack the expertise, facilities or credentials to provide the necessary treatment. The lack of education that dental students receive influences the number of dentists

currently in practice who treat patients with special needs.9 This coupled with poor reimbursement rates from Medicaid and other organizations, dissuades general dentists from pursuing patients from this population. While pediatric dentists have additional training for treating children with special needs and often better reimbursement rates from parents and private insurance companies, there are very few general dentists who can continue to provide regular treatment for these patients once they become adults. One study shows that only 10% of general dentists are providing care for persons with special needs often.10

© 2015 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12110

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BARRIERS TO DENTAL CARE ACCESS

Hy pothes is

The hypothesis of this research study is that finding a dentist willing to treat is the most limiting barrier for access to dental care for special needs patients in Oakland County. The second hypothesis is that adults with special needs have a more difficult experience with access to dental care, in comparison to children with special needs. The third hypothesis is that demographics influence access to care for special needs patients.

M ethods

A paper survey was sent to 385 students at six special education schools and developmental centers in Bloomfield Hills, Farmington Hills, Waterford, and Hazel Park that are all located in Oakland County, Michigan. The students that were surveyed are 3 to 26 years of age. The range of ages allowed for comparisons to be made between children and adults with special needs. The survey contains 18 questions and space for comments. (Figure 1) The surveys were filled out by the parents or caregivers of the students and returned by postage provided mail. The surveys were anonymous but color-coordinated in order to identify the city that was surveyed. There was a 30% response rate with 117 surveys returned. There were 42 responses from Bloomfield Hills, 53 from Farmington Hills, 10 from Waterford, and 12 from Hazel Park. (Table 1)

R es u lts

Survey responders were asked to rank the following barriers on a scale of 1 to 10, with 10 being the most difficult: finances, transportation, finding a dentist willing to treat, distance, and wait time. The answers were grouped into three categories: easy (1 to 3), somewhat difficult (4 to 7), and difficult (8 to 10). The most limiting barrier was finding a dentist willing to treat with 34.2% responding that this barrier was difficult compared to finances (17.6%), wait time (14.4%), distance (12.4%), and transportation

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Figure 1. Survey.

(1.9%). (Figure 2) This finding is consistent with other studies, one that found 40% of caretakers in Florida responding about the difficulty of finding comprehensive care for patients with special needs, and another in Alabama that found 33.6% of their surveyed population responding that finding a dentist able to treat their children was the main barrier.11,12 The actual percentage most likely would be greater if there was a

higher survey response rate, under the assumption that the parents/caregivers who responded are most likely more active and involved in seeking dental treatment for their child.12 The same ranking of barriers was grouped according to ages: 6 years and under, 7 to 12 years, 13 to 17 years, 18 to 22 years, and 23 years and older. There was a significant difference among the age groups. With increased age, there is

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increased difficulty with all the barriers, especially in finding a dentist willing to treat. Figure 3 shows the percentage of responders that ranked the five barriers as difficult based on their age group. The 23 years and older group consistently ranked barriers to dental care access as more difficult than the younger age groups. The increased difficulty that the older students had in finding a dentist is illustrated in the mean values of each age group. The younger students (3 to 17) had a mean level of difficulty of 3.79, while the older students (18 to 26) had a mean level of difficulty of 5.45. The most notable finding that demonstrates the difficulty for dental care access is the number of responders that answered that they do not even have a dentist. Of the student surveys received, 23 students, 20% of the surveys, indicated that the student did not have a dentist currently. Of these responses, 65% were from the 18 to 22 and 23 and older age groups. (Figure 4) 27% of the students that are 23 years and older have not found a dentist, demonstrating the difficulty for adults with special needs to find access to care. Another finding in this study is that there is a direct correlation between demographics and dental care access for finding a dentist willing to treat. (Figure 5) Oakland County has the second highest household income in the state of Michigan at $65,637 with a population of over 1.2 million people.1 The four cities that participated in the survey vary greatly within Oakland County. Despite this, the main barrier for each city was consistently finding a dentist willing to treat. The difficulty, however, increased inversely with a decreased

Figure 1. Continued.

Table 1. Number of Responses Based on City and Age. Ages 6 years and under

Bloomfield Hills

Farmington Hills

Waterford

Hazel Park

Total

(42 Responses)

(53 Responses)

(10 Responses)

(12 Responses)

(117 Responses)

4

0

0

3

7

7 to 12 years

8

3

2

3

16

13 to 17 years

11

10

4

1

26

18 to 22 years

13

22

3

3

41

23 years and older

5

18

1

2

26

N/A

1

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1

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Figure 2.  

Figure 3.  

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Figure 4.  

Figure 5.  

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Figure 6.  

median income. In Bloomfield Hills, the wealthiest city in Michigan, 25.6% of the participants ranked finding a dentist willing to treat as difficult and 17.9% ranked finances as difficult.13 Farmington Hills had the second highest median income of the cities that were surveyed with 30.6% responding that finding a dentist willing to treat is difficult and 16.3% ranked finances as difficult.1 Waterford, with a median income lower than the county's average, responded with 60% ranking finding a dentist willing to treat as difficult and 10% ranking finances as difficult. Hazel Park, with the lowest median income of the cities surveyed, responded with 58.3% of participants ranking finding a dentist willing to treat as being difficult and 33.3% ranking finances as difficult. Surprisingly, the ranking of finances, wait time, distance, and transportation as barriers is not significant and does not show a correlation between demographics and access to dental care. Although the schools and developmental centers are located in separate cities, the students come from all over Oakland

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County and their placement is based on not only proximity but availability as well. Figure 5 shows that there is increased difficulty in finding a dentist willing to treat as the median income decreases. Comparing the responses of those who said they still have not found a dentist for their child, there was a significant difference with 58.3% of the Hazel Park participants responding that they do not have a dentist currently (Figure 6).

Di sc us s ion

The wealthiest city in Michigan, Bloomfield Hills, has a significant number of parents/caregivers responding that it is difficult to find a dentist that is willing to treat their special needs student. This barrier continued to worsen with decreases in financial demographics, but not particularly because of finances itself. The most likely reasons for the upward trend of difficulty in finding a dentist willing to treat with decreased income are decreased education and resources from the schools and ­community to assist these parents

and caregivers. Institutionalization for people living with special needs has become less common, with people living either with family or in a group home.14 With the increased independence that groups provide, there is the disadvantage of not having public medical and dental services provided.10,14 Family members and group homes are instead responsible for finding and providing health care for these individuals. During a PTO meeting at the school in Bloomfield Hills, it appeared that the parents were actively involved, sharing with each other information related to which health care providers their children were seeing. It was unknown if the other schools were as active in their networking. Another possibility is that there may be more students living at home in Bloomfield Hills, as opposed to living in group homes. The surveys were filled out by both parents and caregivers but were not asked to indicate whether the student lived with parents or in a group home. Group homes may find it more difficult to find access to care due to a higher demand of the special needs individual and/or difficulty of group homes to organize medical/dental care for multiple persons. The students that are in group homes may be older in age as well. The age range of the schools allowed both children and adults to be surveyed for a comparison. It is evident that there is a lack of continuum of care for young adults with disabilities who are transitioning from pediatric clinics to general practice offices.9 A frequent survey comment mentions this loss of dental care that their child experienced as they aged out of the pediatric clinic. While some indicated that their young adult was still able to receive treatment in a pediatric clinic, advanced dental needs, increased patient size, and more complicated medical conditions limit the number of special needs adult patients that can continue to obtain treatment in a pediatric office. These patients would be better suited for treatment by an adequately trained general dentist in a clinical setting designed to handle these unique considerations. Hence, access to dental care for adults with special needs is a major concern that

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is desperately in need of change. Part of the problem lies within the system of transitioning adults from pediatric to ­general dentists, where a lack of resources and training hinder a continuum of care.9 A study conducted in 2009 surveyed ­pediatric dentists and examined their procedures for transitioning patients with special needs.6 Seventy percent of the pediatric dentists identified the lack of general dentists as the main barrier for this transition.6 The study concluded that policies and guidelines between pediatric and general dentists are necessary to ­provide transitioning support.6 It would also be beneficial if schools, group homes, and medical offices that work closely with the special needs population were given the resources to help transition and locate general dentists able to treat these patients. The databases that are currently available to help locate dentists are inadequate and require recruitment of general dentists to promote their services to treat special needs. The Michigan Dental Association and Oakland County Dental Society have campaigned to find dentists willing to treat patients with special needs, but access to care continues to be lacking. Education of the general dentist is necessary as well to increase access. Currently, dental school education has inadequate training for special care dentistry and reflects on the confidence of general dentists to treat these individuals.9,15,16 The Commission on Dental Accreditation states in its latest standards that in order to graduate dental students must be competent in the “assessment” but it fails to recognize the ability to provide “treatment” of special needs patients.15 This results in patients only being assessed and then referred to hospitals and/or community clinics which may be over capacity and unable to meet the large demand. Incentives for graduating dental students, such as government funded loan repayment opportunities, could be a driving force to recruit dental students to spend time in a general practice residency program after graduation that provides a quality experience with special care dentistry. General dentists have limited training for treating patients with disabilities and there is a limited focus on special care dentistry in continuing edu-

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cation.10 Requiring continuing education credits in the category of special care dentistry for current general dentists to continue licensure could help to increase education and awareness of a significant access to care issue that exists even in an affluent metropolitan area. Lastly, reimbursements from Medicaid for dental services rendered to special needs patients must be increased to cover the time and cost of providing this advanced care.

Co n clus ion

Even in one of the most affluent counties in the country, there are a significant number of special needs patients that cannot find dental care. This barrier to oral healthcare is a result of low reimbursement levels from Medicaid, a lack of general dentists who are comfortable and willing to treat special needs patients, low community recognition of the importance of dental care, and lack of sharing of resources by schools, families, and medical professionals to assist the special needs population.

Ack now l ed gem ent s

The authors wish to thank Wilbur Smith, M.D., Director of Medical Education St. Joseph Mercy Oakland Hospital, and Thomai Gersh, Supervisor of Special Education at Wing Lake Developmental Center, for their support and collaboration.

Co n f lict s of int er es t There is no conflict of interest.

References 1. Community Health Needs Assessment St. Joseph Mercy Oakland Available at: http://www.stjoesoakland.org/documents5/ 2012CHNAFINAL2.pdf, 2012. 2. Department of Health and Human Services Health Resources and Service Administration Special Care Needs Reference. Available at: http://michigan.gov/documents/mdch/ Dental_Directory_Treating_Patients_with_ Special_Care_Needs_1_289223_7.pdf. 3. Employment and Disability Institute. Cornell University 2013. ­disabilitystatistics.org.

4. Faulks D, Freedman L, Thompson S, Sagheri D, Dougall A. The value of education in ­special care dentistry as a means of reducing inequalities in oral health. Eur J Dent Educ 2012;16:195-201. 5. United States Census Bureau–State and County Quick Facts. Available at: http:// quickfacts.census.gov/qfd/states/26/26125. html. Accessed March 27, 2014. 6. World Media Group, LLC. www.USA.com, 2010. 7. Clemetson JC, Jones DL, Lacy ES, Hale D, Bolin KA. Preparing dental students to treat patients with special needs: changes in p ­ redoctoral education after the revised accreditation standard. J Dent Educ 2012;76:1457-65. 8. Parish CL, Singer R, Abel S, Metsch LR. Addressing the oral healthcare needs of special needs children: pediatric nurses’ self = ­perceived effectiveness. Spec Care Dentist 2014; 34(2):88-95. 9. Rapalo DM, Davis JL, Burtner P, Bouldin ED. Cost as a barrier to dental care among people with disabilities: a report from the Florida behavioral risk factor surveillance system. Spec Care Dentist 2010;30:133-9. 10. The Oakland Web. www.oaklandweb.com/ organizations/hospitals.htm. Accessed August 1, 2014. 11. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating the transition of patients with special health care needs from pediatric to adult oral health care. J Am Dent Assoc 2010;141(11):1351-6. 12. Waldman, Barry H, Perlman SP, Rader R. The transition of children with disabilities to adulthood—what about dental care? J Am Dent Assoc 2010;141:937-8. 13. Hiroko I, Charlotte L, Chuan Z, Louise N, David G. Dental care needs, use and expenditures among U.S. children with and without special health care needs. J Am Dent Assoc 2010;141:79-88. 14. Alagili DE, Roseman J, Pass MA, Thornton JB, Chavers S. Access to dental care in Alabama for children with special needs—parents’ perspectives. J Am Dent Assoc 2004;135:490-5. 15. Wolff A, Waldman H Barry, Milano M, Perlman S. Dental students’ experiences with and attitudes toward people with mental retardation. J Am Dent Assoc 2004;135:353-7. 16. Pradhan A, Slade G, Spencer A. Access to dental care among adults with physical and intellectual disabilities: residence factors. Aust Dent J 2009;54:204-11.

Barriers to dental care access

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Barriers to dental care access for patients with special needs in an affluent metropolitan community.

The number of adults with developmental and acquired disabilities is growing and there are not enough general dentists treating special needs patients...
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