DENTISTRY FOR JORDANIANS WITH SPECIAL NEEDS
ARTICLE ABSTRACT There are thousands of residents with disabilities in Jordan. Despite national legislation to assure individuals with disabilities needed services, including education and employment, social inclusion of these individuals is difficult since societal views exclude them from functioning as members of a community. While there are no national studies of the dental needs of individuals with disabilities in Jordan, local reports indicates limited use of dental services and the need for increased oral hygiene and restorative services. Examples of dental education accreditation standards in other countries are used as models for the improvement in the preparation of dental students to provide services for individuals with special needs.
KEY WORDS: intellectual, developmental disabilities
Dentistry for Jordanians with special needs H. Barry Waldman, DDS, MPH, PhD;1 Steven P. Perlman, DDS, MScD, DHL (Hon)2 1Distinguished
Teaching Professor, Department of General Dentistry, School of Dental Medicine, Stony Brook University, Stony Brook, New York; 2Global Clinical Director, Special Olympics, Special Smiles, Clinical Professor of Pediatric Dentistry, Boston University School of Dental Medicine, Boston, Massachusetts. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(5): 246-250, 2014
Int r od uct ion
The proportion of the population with disabilities in the Hashemite Kingdom of Jordan has been reported as low as 2% in the population census (70,000 individuals with disabilities), but ranges to 3% to 4% by the World Bank (a minimum of 194,000 persons with disabilities) and 12.6% as reported by the Jordanian Ministry of Social Development (or more than 819,000 persons with disabilities of the total population of 6.5 million).1,2 In addition, the accuracy of these figures “… have been hampered by the reluctance of leaders in (Palestinian refugee) camps to acknowledge that disability is even a problem.” Note: “…32.8% of the total (Jordanian) population constitutes Palestinian refugees.”2 While 79% of the population resides in urban communities, Bedouin-Arabs are another significant population subgroup in Jordan that lives in dessert areas. As a nomadic group with particular lifestyle and value systems, as well as social status, origin, and organization, they present a challenge in determining the number and type of disabilities occurring in their population and providing the needed services.2,3 Despite the lack of accuracy of statistics concerning the number of people living with disabilities in Jordan, the most common disabilities are thought to be Down Syndrome, autism, attention deficit disorder, intellectual disabilities, spina bifida, muscular atrophy, cerebral palsy, hearing and visual impairments. Reflecting the demographic structure of the population (e.g., 35.3% of population is less than 15 years of age) the largest proportion of Jordanian population living with disabilities falls
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within the age groups of less than years 15 and 15 to 29 years.4
Met h od ol og y
Supporting Islamic references were drawn from the Google search engine using specific words, e.g., Islam, Muslim, Disabilities, and the paper written by M.S. Bazna and T. A. Hatab.5
Legislation “In its 2006 Concluding Observations, the Committee on the Rights of the Child expressed its continuing concern about de facto discrimination faced by children with disabilities owing to the “inadequate implementation of the 1993 Law on the Care of the Disabled.”4 Among the steps that have been taken to improve the realization of the rights of children living with disabilities, was the adoption of legislation detailing the rights of persons with disabilities in 2007.4
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12061
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DENTISTRY FOR JORDANIANS WITH SPECIAL NEEDS
“Goals proposed by Jordan want to assure that all children (with disabilities) have access to free public education that prepares them to meet their needs as well as offer the tools, training and support for such individuals to lead as independent lives as possible.”6 Jordan has created their own disability rights laws similar to and following the precedent established by the American with Disabilities Act. Jordan’s stand on disability rights in the Middle East has made them a leader in such rights in this region of the world.6 Nevertheless there is concern “…about insufficient allocation of resources to ensure that health care and other services were made accessible to children with disabilities, especially those living in poverty or in rural areas…” 4 In addition, “it is important to note … the Ministry’s of Health’s resistance to supporting any intervention for children living with disabilities until they reach four years of age.”4 In general, “…health conditions in Jordan are among the best in the Middle East. This is due in large part to the kingdom’s stability and to a range of effective development plans and projects which have included health as a major component … The main goal of Jordan’s health strategy has been to provide adequate health coverage to all.”7 The life expectancy at birth is 78.8 years for males and 81.6 years for females.3
Disability, religion, and cultural norms It is possible to identify an Islamic version of the philosophy of equal rights for people with impairments. “For example, there is an episode in the Holy Qur’an which tells of God reprimanding his Prophet when he turned his back on a blind man who asked for advice and knowledge. On this basis, it might be argued that God wishes all members of Islamic society to receive equal treatment, irrespective of impairment. On the other hand, however, there are several verses in the Qur’an and Hadith (the religious texts of Islam) that reveal a much less accommodating, even discriminatory, attitude to disabled people. Unfortunately … within Jordan (it)
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would seem to suggest that negative rather than positive attitudes to impairment are the more dominant – especially in rural areas.”8 Nevertheless, the fact is that, “the word ’disability’ cannot be found within the Qur’an or Hadiths, but the concept of Muslims having inabilities or special needs and how they interacted in society can be found throughout the history of Islam.”9 “Central to a discussion on disability in the Qur’an is the concept of perfection from the Islamic perspective.” 10 “As long as we have to do with human, biological limited being, we cannot possibly consider the idea of ’absolute’ perfection, because everything absolute belongs to the realm of Divine attributes alone.”5 The belief of Muslims is that individuals are created with different abilities and disabilities with the objective to focus on their abilities and show gratefulness rather than focus on the disability. “A Muslim has the right to improve the situation of their disability through prayer, medical, educational and advocacy resources.”5 “Humans’ ’duty is to make the beset of [themselves] so that they might honor the life-gift which [their] Creator has bestowed upon [them]; and to help [their] fellow-beings, by means of [their] own development, in their spiritual, social and material endeavors. But the form of [one’s] individual life is in no way fixed by a standard.’”5 “God’s measure of a human being’s worth relies not on physical attributes or material achievements, but on spiritual maturity and ethical development. The Prophet most explicitly communicates this message when saying: ’Verily, God does not look at your bodies or your appearance, but looks into your hearts.’”5 There are allowances for Muslims with disabilities and the aged to be exempted from some of the Islamic practices such as prayers, fasting and performing hajj—the pilgrimage to Mecca. It is the fifth pillar of Islam, an obligation that must be carried out at least once in their lifetime by every ablebodied Muslim who can afford to do so. It is a demonstration of the solidarity of the Muslim people, and their submission
to God.11 Nevertheless, “all people are expected to constantly do the best they can within their powers, and people with certain conditions are no exception.”12 For example, individuals with intellectual disabilities are exempted from Islamic practices such as fasting and prayers while others with other types of disabilities are not exempted. They only have license to do these practices in a manner within their abilities. Due to the diversity of medical conditions and disabilities, “… it is a preferred practice to refer to a Muslim religious leader to determine what (if any) exemptions of Islamic practices are placed upon a person with a disability or the aged …The community as a whole is enjoined to be accepting of all people regardless of their disability and Muslims are required to support them in addressing their needs…”9 Caring for a family member with a disability is viewed as being highly rewarding. The “…followers of Islam have no more excuse for refusing to take every measure and action in order to protect those who are weak.”12 In general, Muslim care providers prefer to remain with the individual in need at all times and prefer to have activities that involve the whole family. In Islam, the body is a gift from God and needs to be looked after and not abused. Keeping the body healthy is part of one’s religion. Any illness is to be received with patience and prayers and Muslims are strongly encouraged to seek treatment and care. Essentially, “… Islam sees disability as ’morally neutral’. It is neither a blessing nor a curse… It is simply a fact of life which has to be addressed appropriately by the society of the day.”13 • The reality is that when it comes to disabilities, “culturally embedded attitudes render the severity of an impairment inconsequential compared to the social consequence of disablement.”2Writing in a UNESCO publication on the marginalization of people with disabilities, the author comments that in a traditional Jordanian household, “…a girl child with a slight disfigurement may be fully functional, but considered
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impure and unfit for marriage, making education unnecessary in the eyes of the parents. By contrast a boy with a more severe impairment within the same household might be sent to school and given sports that greatly diminish the influence of the impairment.”2 Others comment that, the concern regarding female children is not related to marriage-ability; rather it has to do with the attitude of healthy children at the school. The Jordan Ministry of Education has regulations regarding the acceptance of children with disabilities in regular school.6 • The birth of a disabled child is seen by many as not only a misfortune, but as shameful and embarrassing. The husband’s family is likely to blame the misfortune on the mother… and likely to consign (the) mother to a lifetime of misery…”2 With crowded cities, uneven sidewalks and chaotic traffic, Jordan is far from ideal for people with disabilities. (Nevertheless,) “Jordan is a leader among Arab countries for recognizing people with disabilities.”14
Specifically dentistry In Jordan, the oral health system is in a transitional developmental stage, and systematic data collection is needed to plan oral health care for the public. Comprehensive preventive programs for oral health care are still lacking in Jordan, so more dental health education is needed to improve oral health standards among Jordanians.15 Since the early 1990s, oral hygiene, gingival conditions, and dental caries have improved among school children of north Jordan.16 Other studies on school children in north Jordan showed that dental plaque, calculus, and dental caries were reported higher than destructive periodontal disease.17,18 The incidence of both gingivitis and dental caries in a percentage of Jordan school children was found to be higher than that of school children in developed countries.19 The results of a study of oral health attitudes, knowledge and behavior among Jordanian school children indicated that, “…children’s and
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parents’ attitude toward oral health and dental care need to be improved. Comprehensive oral health education programs for both children and their patients are required to achieve this goal.” 11 Other studies reported that oral health habits were poor with an additional lack of parental knowledge regarding oral conditions. Each study ended with a call for school and community oriented oral health programs.20–22 Specifically for teenagers with Down syndrome in special needs centers in Jordan, it was reported that despite more dental abnormalities and poorer periodontal health than non-Down syndrome students, these teenagers had less visits for dental services because their parents were “not aware of the dental problems of their children.” 23
Why the concerns for oral health care? The many difficulties faced by thousands of individuals with disabilities in Jordan may seem endless. In such an environment, the need for dental care would at best seem to be a marginal afterthought. Nevertheless, the needs are real, especially for individuals with special needs. Kozol succinctly summarized the realities of inadequate oral health services for individuals with and without associated disabilities: “Children (and adults) get used to feeling constant pain… (from) bleeding gums, impacted teeth and rotting teeth… They go to sleep with it. They go to school (and work) with it…The gradual attrition of accepted pain erodes their energy and aspirations.” 24 As young men and women train for careers in the dental and other health professions, opportunities for contact with and care for individuals with disabilities are essential if they are to overcome the all too often standard perceptions and attitudes which result in the rejection, exclusion and discrimination against individuals with disabilities. “Only if early contact is established with patients (with disabilities), practical edu-
cational strategies are adopted, and the students are provided with information on attitudes about the disabled, will a social model of disability be introduced into the curriculum.”25
Dentists and the treatment of individuals with special needs Numerous reasons are stated for not treating people with disabilities in private practice, including: “…too much time is required to perform procedures, the patient may have a life threatening medical emergency, funds for treatment are difficult to obtain, procedures are too difficult or there are difficulties of (physical) access to the (operatory), the dentists neither received special training, nor have they the special equipment, and they are apprehensive dealing with disabled people, other patients may be offended (e.g., waiting room disturbances) (sic) and these disabled patients usually require hospitalization.”26
Dental school programs This need for “experience and contact with people with disabilities” was the basis for establishing dental school accreditation requirements to ensure adequate basic science and clinical experience in the predoctoral training programs in many dental schools in other countries. For example, in Canada and the United States: “Graduates must have sufficient clinical and related experiences to demonstrate competency in the management of the oral health care for patients of all ages. Experiences in the management of medicallycompromised patients and patients with disabilities and/or chronic conditions should be provided.” (Standard 2.4.1)27 “Graduates must (sic) be competent in assessing the treatment needs of patients with special needs.” (Standard 2–26)28
The challenge The need is for schools of dentistry to follow the accrediting steps taken by the
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dental profession in other countries to ensure the adequate basic science and clinical experience in predoctoral clinical programs to prepare graduates to provide for the wide range of individuals with special needs. However, developing such an effort is possible only if the profession and the general public can be convinced of the need for these programs. To this end: • “There is a need for a national health survey (including oral health) of people with disabilities with particular emphasis on the conditions in the rural areas. The current limited series of reports emphasize the conditions in the major urban areas. • There is a need to identify the type and availability of current dental service centers for individuals with disabilities. Such an effort to catalogue dental school and health department programs, as well as the number of private dental practitioners, would provide an essential basis for lobbying for improved educational programs and service arrangements. • There is a need to enhance national organizations to stimulate an awareness of the varied needs of individuals with disabilities. Such organizations would serve as an advocate to raise standards, to support demonstration programs and lobby to increase the commitment to have children with disabilities (where possible) placed in the regular school system, to increase employment opportunities and to foster acceptance in the general community.”29,30 Only then can one anticipate the establishment of real programs in schools to prepare dental students to care for individuals with disabilities. Such an effort cannot be relegated to small groups of trained specialists. The reality is that such an effort can be successful only with trained specialists (e.g., pediatric dentists) and the participation of general practitioners who have been prepared to provide these needed services.31
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Co nf lict of int er es t
There is no requirement at our institutions for such work to be approved by ethical committees. There are no conflicts of interest. There was no specific financial support for this paper, nor has it been presented before any particular group.
References 1. JICA Friends. Jordan: disability related information. Available at: http://www. jicafriends.jp/world/profile/middle/jordan. html. Accessed August 8, 2012. 2. UNESCO. Peters SJ. Review of marginalization of people with disabilities in Lebanon, Syria and Jordan. Background paper prepared for the Education for All Global Monitoring Report 2010. Available at: http://www.unesco.org/new/fileadmin/ MULTIMEDIA/FIELD/Beirut/pdf/ Background%20paper%20EFA%20 2010-Marginalization%20in%20Jordan%20 Syria%20and%20Lebanon.pdf. Accessed August 22, 2012. 3. Index Mundi. Jordan demographic profile: 2012. Available at: http://www.indexmundi. com/jordan/demographics_profile.html. Accessed August 23, 2012. 4. Swedish International Development Cooperation Agency. Country profile of Jordan: a review of the implementation of the UN Convention on the Rights of the Child, August 2011. Available at: http:// www.iber.org/editor/assets/Jordan%20County %20Profile/pdf. Accessed August 24, 2012. 5. Bazna MS, Hatab TA. Disability in the Qur’an: the Islamic alternative to defining, viewing and relating to disability. Available at: http://www.lancs.ac.uk/fass/events/disabilityconference_archive/2004/abstracts/ bazna.htm. Accessed December 17, 2012. 6. Placid Way. Jordan encourages education and rehabilitation for the disabled. Available at: http://www.placidway.com/article/ 447/Jordan-Encourages-Education-andRehabilitation-for-the-Disabled. Accessed August 24, 2012. 7. Embassy of the Hashemite Kingdom of Jordan. Health and Social Development. Available at: http://www.jordanembassyus. org/new/jib/factsheets/health.shtml. Accessed August 23, 2012.
8. Turmusani M. Disability policy and provision in Jordan: a critical perspective. In: Stone E., ed. Disability and development: learning from action and research on disability in the majority world. Leeds: The Disability Press, 1999: 193-209. Available at: http://www.leeds.ac.uk/ disability-studies/archiveuk/stone/chapter% 2012.pdf. Accessed August 20, 2012. 9. Al Thani H. Disability in the Arab region: current situation and prospects. J Disabil Int Dev 2006;3:4-9. 10. Asad M. Islam at the crossroads. Kuala Lumur, Malaysia: The Other Press, 1999 (Original work published 1987); in Bazna MS, Hatab TA, op cit. 11. Hajj. Wikipedia. Available at: http://en. wikipedia.org/wiki/Hajj. Accessed August 28, 2012. 12. Asad M. Message of the Qur’an. Lahore, Pakistan: Maktaba Jawahar Ul Uloom, 1980; in Bazna MS, Hatab TA, op cit. 13. What does Islam say about disability? Available at: http://muslimyouth.net/print_ article.php?a_id=474&id_fk=17&id_fkis= 59&id_fkt=197. Accessed August 28, 2012. 14. Richinick M. Northeastern University. Jordan is a leader among Arab countries for recognizing people with disabilities. Available at: http://northeasternuniversityjournalism2011.wordpress.com/2011/05/26/ jordan-is-a-leader-among-arab-countriesfor-recognizing-people-with-disabilities. Accessed August 28, 2012. 15. Al-Omiri MK, Al-Wahadni AM, Saeed KN. Oral health attitudes, knowledge, and behavior among school children in Northern Jordan. J Dent Educ 2006;70:179-87. 16. Taani DQ. Trends in oral hygiene, gingival status and dental caries experience in 13–14-year-old Jordanian school children between 1993 and 1999. Int Dent J 2001;51: 277-81. 17. Taani DQ. The periodontal status of Jordanian adolescents measured by CPITN. Int Dent J 1995;45:382-5. 18. Taani DQ. Caries prevalence and periodontal treatment needs in public and private school pupils in Jordan. Int Dent J 1997;47:100-4. 19. Taani DQ. Relationship of socioeconomic background to oral hygiene, gingival status, and dental caries in children. Quintessence Int 2002;33:1-4. 20. Al-Bashtawy M. Oral health patterns among schoolchildren in Mafraq Governorate, Jordan. J School Nursing 2012;28:124-8.
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21. El-Qaderi SS, Taari DQ. Oral health knowledge and dental health practices among schoolchildren in Jerash district Jordan. Int J Dent Hyg 2004;2:78-85. 22. Owais Al, Zawaideh F, Bataineh O. Challenging parents’ myths regarding their children’s teething. Int J Dent Hyg 2010;1:28-34. 23. Al Habashneh R, Al-Jundi S, Khader Y, Nofel HN. Oral health status and reason for not attending dental care among 12–16-year old children with Down syndrome in special needs centres in Jordan. Int J Dent Hyg 2012 Feb 16. doi: 10.1111/j.1601–5037. 2012.00545.x. (Epub ahead of print). 24. Kozol J. Savage inequities: children in America’s school. New York: Harper Perennials, 1999:20–1.
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25. Sahin H, Akyol AD. Evolution of nursing and medical students’ attitudes towards people with disabilities. J Clin Nurs, 2010. Available at: http://www.ncbinlm.nih.gov/ pubmed/20522157. Accessed July 15, 2010. 26. Alaqcam A, Yildirim S, Cinar C, Bal C, Gurbuz F. The evaluation of the approach of Turkish dentists to oral health of disabled patients: a pilot study. Brit J Dev Disab Dis 2004;50(1):47-57. 27. Commission on Dental Accreditation of Canada. Accreditation Requirements for Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) Programs. Updated November 30, 2006. Available at: http://www.cda-adc.ca/cdacweb/en/. Accessed August 25, 2012.
28. Commission on Dental Accreditation. Accreditation Standards for Dental Education Program; Modified February 1, 2008. Standard 2–26. Available at: http:// www.ada.org/prof/ed/accred/standards/ predoc.pdf. Accessed August 28, 2012. 29. Waldman HB, Al-Nowaiser AM, Hamed MT, Perlman SP. Dentistry for individuals with special needs in Saudi Arabia: a commentary. J Disab Oral Hlth 2010;11:57–60. 30. Waldman HB, Adiwoso AW, Perlman SP. Dentistry for Indonesians with special needs. A commentary. J Indonesian Dent Assoc 2012;61:1-4. 31. Waldman HB, Perlman SP. A special care dentistry specialty: sounds good, but… J Dent Educ 2006;70(10):1099-102.
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ARTICLE ABSTRACT There are thousands of residents with disabilities in Jordan. Despite national legislation to assure individuals with disabilities needed services, including education and employment, social inclusion of these individuals is difficult since societal views exclude them from functioning as members of a community. While there are no national studies of the dental needs of individuals with disabilities in Jordan, local reports indicates limited use of dental services and the need for increased oral hygiene and restorative services. Examples of dental education accreditation standards in other countries are used as models for the improvement in the preparation of dental students to provide services for individuals with special needs.
KEY WORDS: intellectual, developmental disabilities
Dentistry for Jordanians with special needs H. Barry Waldman, DDS, MPH, PhD;1 Steven P. Perlman, DDS, MScD, DHL (Hon)2 1Distinguished
Teaching Professor, Department of General Dentistry, School of Dental Medicine, Stony Brook University, Stony Brook, New York; 2Global Clinical Director, Special Olympics, Special Smiles, Clinical Professor of Pediatric Dentistry, Boston University School of Dental Medicine, Boston, Massachusetts. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(5): 246-250, 2014
Int r od uct ion
The proportion of the population with disabilities in the Hashemite Kingdom of Jordan has been reported as low as 2% in the population census (70,000 individuals with disabilities), but ranges to 3% to 4% by the World Bank (a minimum of 194,000 persons with disabilities) and 12.6% as reported by the Jordanian Ministry of Social Development (or more than 819,000 persons with disabilities of the total population of 6.5 million).1,2 In addition, the accuracy of these figures “… have been hampered by the reluctance of leaders in (Palestinian refugee) camps to acknowledge that disability is even a problem.” Note: “…32.8% of the total (Jordanian) population constitutes Palestinian refugees.”2 While 79% of the population resides in urban communities, Bedouin-Arabs are another significant population subgroup in Jordan that lives in dessert areas. As a nomadic group with particular lifestyle and value systems, as well as social status, origin, and organization, they present a challenge in determining the number and type of disabilities occurring in their population and providing the needed services.2,3 Despite the lack of accuracy of statistics concerning the number of people living with disabilities in Jordan, the most common disabilities are thought to be Down Syndrome, autism, attention deficit disorder, intellectual disabilities, spina bifida, muscular atrophy, cerebral palsy, hearing and visual impairments. Reflecting the demographic structure of the population (e.g., 35.3% of population is less than 15 years of age) the largest proportion of Jordanian population living with disabilities falls
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within the age groups of less than years 15 and 15 to 29 years.4
Met h od ol og y
Supporting Islamic references were drawn from the Google search engine using specific words, e.g., Islam, Muslim, Disabilities, and the paper written by M.S. Bazna and T. A. Hatab.5
Legislation “In its 2006 Concluding Observations, the Committee on the Rights of the Child expressed its continuing concern about de facto discrimination faced by children with disabilities owing to the “inadequate implementation of the 1993 Law on the Care of the Disabled.”4 Among the steps that have been taken to improve the realization of the rights of children living with disabilities, was the adoption of legislation detailing the rights of persons with disabilities in 2007.4
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12061
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“Goals proposed by Jordan want to assure that all children (with disabilities) have access to free public education that prepares them to meet their needs as well as offer the tools, training and support for such individuals to lead as independent lives as possible.”6 Jordan has created their own disability rights laws similar to and following the precedent established by the American with Disabilities Act. Jordan’s stand on disability rights in the Middle East has made them a leader in such rights in this region of the world.6 Nevertheless there is concern “…about insufficient allocation of resources to ensure that health care and other services were made accessible to children with disabilities, especially those living in poverty or in rural areas…” 4 In addition, “it is important to note … the Ministry’s of Health’s resistance to supporting any intervention for children living with disabilities until they reach four years of age.”4 In general, “…health conditions in Jordan are among the best in the Middle East. This is due in large part to the kingdom’s stability and to a range of effective development plans and projects which have included health as a major component … The main goal of Jordan’s health strategy has been to provide adequate health coverage to all.”7 The life expectancy at birth is 78.8 years for males and 81.6 years for females.3
Disability, religion, and cultural norms It is possible to identify an Islamic version of the philosophy of equal rights for people with impairments. “For example, there is an episode in the Holy Qur’an which tells of God reprimanding his Prophet when he turned his back on a blind man who asked for advice and knowledge. On this basis, it might be argued that God wishes all members of Islamic society to receive equal treatment, irrespective of impairment. On the other hand, however, there are several verses in the Qur’an and Hadith (the religious texts of Islam) that reveal a much less accommodating, even discriminatory, attitude to disabled people. Unfortunately … within Jordan (it)
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would seem to suggest that negative rather than positive attitudes to impairment are the more dominant – especially in rural areas.”8 Nevertheless, the fact is that, “the word ’disability’ cannot be found within the Qur’an or Hadiths, but the concept of Muslims having inabilities or special needs and how they interacted in society can be found throughout the history of Islam.”9 “Central to a discussion on disability in the Qur’an is the concept of perfection from the Islamic perspective.” 10 “As long as we have to do with human, biological limited being, we cannot possibly consider the idea of ’absolute’ perfection, because everything absolute belongs to the realm of Divine attributes alone.”5 The belief of Muslims is that individuals are created with different abilities and disabilities with the objective to focus on their abilities and show gratefulness rather than focus on the disability. “A Muslim has the right to improve the situation of their disability through prayer, medical, educational and advocacy resources.”5 “Humans’ ’duty is to make the beset of [themselves] so that they might honor the life-gift which [their] Creator has bestowed upon [them]; and to help [their] fellow-beings, by means of [their] own development, in their spiritual, social and material endeavors. But the form of [one’s] individual life is in no way fixed by a standard.’”5 “God’s measure of a human being’s worth relies not on physical attributes or material achievements, but on spiritual maturity and ethical development. The Prophet most explicitly communicates this message when saying: ’Verily, God does not look at your bodies or your appearance, but looks into your hearts.’”5 There are allowances for Muslims with disabilities and the aged to be exempted from some of the Islamic practices such as prayers, fasting and performing hajj—the pilgrimage to Mecca. It is the fifth pillar of Islam, an obligation that must be carried out at least once in their lifetime by every ablebodied Muslim who can afford to do so. It is a demonstration of the solidarity of the Muslim people, and their submission
to God.11 Nevertheless, “all people are expected to constantly do the best they can within their powers, and people with certain conditions are no exception.”12 For example, individuals with intellectual disabilities are exempted from Islamic practices such as fasting and prayers while others with other types of disabilities are not exempted. They only have license to do these practices in a manner within their abilities. Due to the diversity of medical conditions and disabilities, “… it is a preferred practice to refer to a Muslim religious leader to determine what (if any) exemptions of Islamic practices are placed upon a person with a disability or the aged …The community as a whole is enjoined to be accepting of all people regardless of their disability and Muslims are required to support them in addressing their needs…”9 Caring for a family member with a disability is viewed as being highly rewarding. The “…followers of Islam have no more excuse for refusing to take every measure and action in order to protect those who are weak.”12 In general, Muslim care providers prefer to remain with the individual in need at all times and prefer to have activities that involve the whole family. In Islam, the body is a gift from God and needs to be looked after and not abused. Keeping the body healthy is part of one’s religion. Any illness is to be received with patience and prayers and Muslims are strongly encouraged to seek treatment and care. Essentially, “… Islam sees disability as ’morally neutral’. It is neither a blessing nor a curse… It is simply a fact of life which has to be addressed appropriately by the society of the day.”13 • The reality is that when it comes to disabilities, “culturally embedded attitudes render the severity of an impairment inconsequential compared to the social consequence of disablement.”2Writing in a UNESCO publication on the marginalization of people with disabilities, the author comments that in a traditional Jordanian household, “…a girl child with a slight disfigurement may be fully functional, but considered
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impure and unfit for marriage, making education unnecessary in the eyes of the parents. By contrast a boy with a more severe impairment within the same household might be sent to school and given sports that greatly diminish the influence of the impairment.”2 Others comment that, the concern regarding female children is not related to marriage-ability; rather it has to do with the attitude of healthy children at the school. The Jordan Ministry of Education has regulations regarding the acceptance of children with disabilities in regular school.6 • The birth of a disabled child is seen by many as not only a misfortune, but as shameful and embarrassing. The husband’s family is likely to blame the misfortune on the mother… and likely to consign (the) mother to a lifetime of misery…”2 With crowded cities, uneven sidewalks and chaotic traffic, Jordan is far from ideal for people with disabilities. (Nevertheless,) “Jordan is a leader among Arab countries for recognizing people with disabilities.”14
Specifically dentistry In Jordan, the oral health system is in a transitional developmental stage, and systematic data collection is needed to plan oral health care for the public. Comprehensive preventive programs for oral health care are still lacking in Jordan, so more dental health education is needed to improve oral health standards among Jordanians.15 Since the early 1990s, oral hygiene, gingival conditions, and dental caries have improved among school children of north Jordan.16 Other studies on school children in north Jordan showed that dental plaque, calculus, and dental caries were reported higher than destructive periodontal disease.17,18 The incidence of both gingivitis and dental caries in a percentage of Jordan school children was found to be higher than that of school children in developed countries.19 The results of a study of oral health attitudes, knowledge and behavior among Jordanian school children indicated that, “…children’s and
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parents’ attitude toward oral health and dental care need to be improved. Comprehensive oral health education programs for both children and their patients are required to achieve this goal.” 11 Other studies reported that oral health habits were poor with an additional lack of parental knowledge regarding oral conditions. Each study ended with a call for school and community oriented oral health programs.20–22 Specifically for teenagers with Down syndrome in special needs centers in Jordan, it was reported that despite more dental abnormalities and poorer periodontal health than non-Down syndrome students, these teenagers had less visits for dental services because their parents were “not aware of the dental problems of their children.” 23
Why the concerns for oral health care? The many difficulties faced by thousands of individuals with disabilities in Jordan may seem endless. In such an environment, the need for dental care would at best seem to be a marginal afterthought. Nevertheless, the needs are real, especially for individuals with special needs. Kozol succinctly summarized the realities of inadequate oral health services for individuals with and without associated disabilities: “Children (and adults) get used to feeling constant pain… (from) bleeding gums, impacted teeth and rotting teeth… They go to sleep with it. They go to school (and work) with it…The gradual attrition of accepted pain erodes their energy and aspirations.” 24 As young men and women train for careers in the dental and other health professions, opportunities for contact with and care for individuals with disabilities are essential if they are to overcome the all too often standard perceptions and attitudes which result in the rejection, exclusion and discrimination against individuals with disabilities. “Only if early contact is established with patients (with disabilities), practical edu-
cational strategies are adopted, and the students are provided with information on attitudes about the disabled, will a social model of disability be introduced into the curriculum.”25
Dentists and the treatment of individuals with special needs Numerous reasons are stated for not treating people with disabilities in private practice, including: “…too much time is required to perform procedures, the patient may have a life threatening medical emergency, funds for treatment are difficult to obtain, procedures are too difficult or there are difficulties of (physical) access to the (operatory), the dentists neither received special training, nor have they the special equipment, and they are apprehensive dealing with disabled people, other patients may be offended (e.g., waiting room disturbances) (sic) and these disabled patients usually require hospitalization.”26
Dental school programs This need for “experience and contact with people with disabilities” was the basis for establishing dental school accreditation requirements to ensure adequate basic science and clinical experience in the predoctoral training programs in many dental schools in other countries. For example, in Canada and the United States: “Graduates must have sufficient clinical and related experiences to demonstrate competency in the management of the oral health care for patients of all ages. Experiences in the management of medicallycompromised patients and patients with disabilities and/or chronic conditions should be provided.” (Standard 2.4.1)27 “Graduates must (sic) be competent in assessing the treatment needs of patients with special needs.” (Standard 2–26)28
The challenge The need is for schools of dentistry to follow the accrediting steps taken by the
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dental profession in other countries to ensure the adequate basic science and clinical experience in predoctoral clinical programs to prepare graduates to provide for the wide range of individuals with special needs. However, developing such an effort is possible only if the profession and the general public can be convinced of the need for these programs. To this end: • “There is a need for a national health survey (including oral health) of people with disabilities with particular emphasis on the conditions in the rural areas. The current limited series of reports emphasize the conditions in the major urban areas. • There is a need to identify the type and availability of current dental service centers for individuals with disabilities. Such an effort to catalogue dental school and health department programs, as well as the number of private dental practitioners, would provide an essential basis for lobbying for improved educational programs and service arrangements. • There is a need to enhance national organizations to stimulate an awareness of the varied needs of individuals with disabilities. Such organizations would serve as an advocate to raise standards, to support demonstration programs and lobby to increase the commitment to have children with disabilities (where possible) placed in the regular school system, to increase employment opportunities and to foster acceptance in the general community.”29,30 Only then can one anticipate the establishment of real programs in schools to prepare dental students to care for individuals with disabilities. Such an effort cannot be relegated to small groups of trained specialists. The reality is that such an effort can be successful only with trained specialists (e.g., pediatric dentists) and the participation of general practitioners who have been prepared to provide these needed services.31
Wa l d m a n a n d P e r l m a n
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Co nf lict of int er es t
There is no requirement at our institutions for such work to be approved by ethical committees. There are no conflicts of interest. There was no specific financial support for this paper, nor has it been presented before any particular group.
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21. El-Qaderi SS, Taari DQ. Oral health knowledge and dental health practices among schoolchildren in Jerash district Jordan. Int J Dent Hyg 2004;2:78-85. 22. Owais Al, Zawaideh F, Bataineh O. Challenging parents’ myths regarding their children’s teething. Int J Dent Hyg 2010;1:28-34. 23. Al Habashneh R, Al-Jundi S, Khader Y, Nofel HN. Oral health status and reason for not attending dental care among 12–16-year old children with Down syndrome in special needs centres in Jordan. Int J Dent Hyg 2012 Feb 16. doi: 10.1111/j.1601–5037. 2012.00545.x. (Epub ahead of print). 24. Kozol J. Savage inequities: children in America’s school. New York: Harper Perennials, 1999:20–1.
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25. Sahin H, Akyol AD. Evolution of nursing and medical students’ attitudes towards people with disabilities. J Clin Nurs, 2010. Available at: http://www.ncbinlm.nih.gov/ pubmed/20522157. Accessed July 15, 2010. 26. Alaqcam A, Yildirim S, Cinar C, Bal C, Gurbuz F. The evaluation of the approach of Turkish dentists to oral health of disabled patients: a pilot study. Brit J Dev Disab Dis 2004;50(1):47-57. 27. Commission on Dental Accreditation of Canada. Accreditation Requirements for Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) Programs. Updated November 30, 2006. Available at: http://www.cda-adc.ca/cdacweb/en/. Accessed August 25, 2012.
28. Commission on Dental Accreditation. Accreditation Standards for Dental Education Program; Modified February 1, 2008. Standard 2–26. Available at: http:// www.ada.org/prof/ed/accred/standards/ predoc.pdf. Accessed August 28, 2012. 29. Waldman HB, Al-Nowaiser AM, Hamed MT, Perlman SP. Dentistry for individuals with special needs in Saudi Arabia: a commentary. J Disab Oral Hlth 2010;11:57–60. 30. Waldman HB, Adiwoso AW, Perlman SP. Dentistry for Indonesians with special needs. A commentary. J Indonesian Dent Assoc 2012;61:1-4. 31. Waldman HB, Perlman SP. A special care dentistry specialty: sounds good, but… J Dent Educ 2006;70(10):1099-102.
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