O R A L H E A LT H C A R E I N O N C O L O G Y D E N TA L S U P P O R T C L I N I C
ARTICLE ABSTRACT The purpose of this study was to identify predictors and/or factors associated with medically compromised patients seeking dental care in the oncology dental support clinic (ODSC) at the University of Missouri-Kansas City (UMKC) School of Dentistry. An 18-item survey was mailed to 2,541 patients who were new patients to the clinic from 2006 to 2011. The response rate was approximately 18% (n = 450). Analyses included descriptive statistics of percentages/frequencies as well as predictors based on correlations. Fifty percent of participants, 100 females and 119 males, identified their primary medical diagnosis as cancer. Total household income (p < .001) and the importance of receiving dental care (p < .001) were significant factors in relation to self-rated dental health. Perceived overall health (p < .001) also had a significant association with cancer status and the need for organ transplants. This study provided the ODSC at UMKC and other specialty clinics with vital information that can contribute to future planning efforts.
KEY WORDS: Oncology dental support clinic, oral health
Factors influencing patients seeking oral health care in the oncology dental support clinic at an urban university dental school setting Dale M. Corrigan, RDH, MS;1 Mary P. Walker, DDS, PhD;2 Ying Liu, PhD;3 Tanya Villalpando Mitchell, RDH, MS4* 1Graduate
Dental Hygiene Student; 2Associate Dean for Research and Graduate Programs; Assistant Professor Research and Graduate Programs; 4Associate Professor and Director Graduate Studies Division of Dental Hygiene, University of Missouri-Kansas City School of Dentistry, Kansas City, Missouri. *Corresponding author e-mail: [email protected] 3Clinical
Spec Care Dentist 34(3): 106-113, 2014
Scient if ic a r t icl e cont ent
With a focus on health promotion and disease prevention, the U.S. Department of Health and Human Services (HHS) in 2000 initiated Oral Health in America: A Report of the Surgeon General. The main objective of this initiative is to “improve quality of life and eliminate health disparities by facilitating collaborations among individuals, health care providers, communities, and policymakers at all levels of society and by taking advantage of existing initiatives.”1 Oral health is an essential element to overall general health and quality of life. It is inappropriate to view oral health and general health as separate conditions because they are truly interdependent and one cannot occur without the other.1,2 The Healthy People 2020 initiative was developed with consideration from several previous projects that included the 1979 Surgeon General’s Report, Healthy People 1990, 2000, and 2010.2 The goal as a nation and the emphasis for 2020 is placed on formulating a plan to concentrate on reducing and eliminating health disparities in an effort to obtain health equity. As part of the 2020 topics and objectives, treatment and prevention goals for cancer are specifically addressed. The underlying focus for cancer is to reduce the number of new cases, minimize illnesses associated with the disease, disability, and decrease the number of deaths. It is important to note that decreasing known risk factors,
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receiving proper vaccinations such as those designed to prevent the hepatitis B virus and the human papillomavirus (HPV) and obtaining recommended screenings can all be utilized as appropriate measures to help prevent cancer.2
Med ica l ly c o m p r o m i se d p a t ient s
Cancer is ranked among the top two leading causes of all deaths in the United States (U.S.), trailing heart disease by only 2%.3 A recent report published by the American Cancer Society (ACS) predicted the diagnosis rate of new cancer cases in the U.S. would exceed
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12037
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approximately 1.6 million in 2012.4 Specifically, cancers affecting the oral cavity and pharynx (including the tongue, mouth, pharynx, and other areas of the oral cavity) in both men and women are estimated to account for 40,250 of new cancer cases.4 Recently, the demographic picture for developing oral cancer has changed significantly due to identification of the HPV-16 virus as a contributory factor in the prevalence of cancers in the posterior areas of the mouth (oropharynx).5 This turn of events is of particular importance in regard to oral health and a disease once thought to predominantly affect an aging population. This change in disease demographics reinforces the value of focusing on prevention.2 With a rise in the elderly population and more people in need of organ transplants, there is a greater need to provide specialty oral health care for this medically compromised population.6 Kidney transplants are one of the most common organ transplant procedures performed in the United States. According to the Organ Procurement and Transplantation Network (OPTN), there were 316,493 kidney transplants performed in the U.S. from January 1, 1988 to November 30, 2011.7 As part of the healthcare community, oral health care providers are encouraged to screen patients for high blood pressure during dental visits.8,9 Monitoring blood pressure levels on a regular basis can help determine whether or not patients are maintaining a controlled blood pressure. This is a key factor in treating chronic kidney disease.10 As the numbers continue to increase in regard to the prevalence of oral cancer and end stage renal disease (ESRD), there is a higher probability that oral healthcare providers may encounter patients who are medically compromised. Because of the obvious inherent challenges with this patient population, it is imperative to understand that the complexities of certain medical treatments can be as traumatic as the effects of the disease itself. When providing oral health services to medically compromised patients (MCP), the role of the oral healthcare
Corrigan et al.
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provider is to help guard against further complications due to an already compromised immune system.6,11 With an increased awareness of the difficulties associated with treating the oral health needs of MCP, the value of a dental professional as part of the health team is enhanced. As presented in the Surgeon General’s Report, “oral health is not a given,” it requires a continuous multi-faceted plan and unified approach from the community, caregivers, patients, and healthcare providers. Undoubtedly, well trained dental professionals play a significant role in the movement toward obtaining overall health. Consideration of treatment modalities for MCP should be based on the individual needs of the patient, whether care is provided in a private office setting, community outreach program, or dental school setting. In regard to providing specialized oral healthcare, the importance of educating dental professionals to treat MCP cannot be understated. Realizing this need, the University of Missouri-Kansas City (UMKC) School of Dentistry (SOD) has taken a first step in addressing this issue through establishment and continuity of the oncology dental support clinic (ODSC).
De nt a l ed uca t iona l e xpe r iences
To help improve treatment outcomes for MCPs, it is imperative to provide the appropriate didactic education for dental and dental hygiene students. It is important to create opportunities to treat patients with special needs in a clinical setting as well.12 The curriculum and training components of dental and dental hygiene programs must take into consideration the special needs population in order to help address their underserved dental needs. Incorporating educational and clinical experiences into current educational programs would make a significant difference in servicing the oral health needs of MCP.13-15 This approach also prepares the dental and allied dental hygiene students to treat MCPs upon
graduation from their respective programs. The Commission on Dental Accreditation (CODA) adopted accreditation standards for dental educational programs as defined in Standard 2-Educational Programs in August 2010. Specifically, standard 2–23b (screening and risk assessment for head and neck cancer), 2–24 (assessing treatment need of patients with special needs), and 2–25 (provide opportunities and encourage students to engage in service learning and/or community-based learning experiences) are designed to decrease oral health disparity and address issues related to special patient care (SPC).16 On the forefront of these recommendations, dental schools in New York, West Virginia, Washington, Louisville, Ohio, Florida, and New Jersey have implemented programs aimed at providing care for special patient populations.15 In these schools, the programs are designed to concentrate on developmentally disabled (DD) individuals. There are many complex factors associated with a university based special patient care clinic (SPCC) whether serving DD and/ or MCPs. Dehaitem et al.13 investigated dental hygiene curriculums in the U.S. to see if the programs provided educational opportunities to students in regard to treating special needs patients. Of the 101 schools that responded to the survey, all programs reported they at least touch on this information in the classroom setting. However, less than half of the programs (42%) made the requirement for students to provide treatment to special needs patients within a clinical setting. The remaining dental hygiene programs (56.9%) did not require students to acquire clinical experience in this area. In a study conducted by Vainio et al.14 dental students’ educational experiences, attitudes, and behaviors regarding SPC were examined. Students reported the value in receiving a quality education with a focus on treatment of patients with special needs, leads to more confident attitudes and behaviors when providing patient care. At the UMKC SOD, dental
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and dental hygiene students are given this opportunity through participation in a practicum within the ODSC. The ODSC at the UMKC SOD was originally named the SPCC. It began in 1989 with its purpose of providing educational opportunities for dental and dental hygiene students to learn about the oral complications associated with cancer treatments. As part of their academic experience, undergraduate dental students and practicum dental hygiene students participate in rotations as part of their clinical courses. The ODSC has since served as a clinic where dental evaluations are performed for head and neck cancer patients in the Kansas City and surrounding areas prior to their cancer treatments. In addition, the ODSC provides dental services to a variety of MCPs that includes those with cancer and patients who are in need of organ transplantation.17 Today, the clinic continues to focus on comprehensive collaborative care that includes nonsurgical periodontal therapies, extensive restorative procedures (restorations, crowns, and bridges), removable prosthodontics, and fabrication of intraoral positioning devices used during radiotherapy. A study completed by Schwenk et al.18 identified whether or not a dental school had a separate clinic area to provide oral health care for their patients with special needs. Based on the response to the survey, 40% (17/42) of dental schools reported they had a specific area to treat patients with special needs. This is also true of the ODSC at the UMKC SOD. The majority of the dental schools (41/42) with a SPCC reported they treated patients who were medically compromised. Enhanced education and increased research efforts should be an integrated process employed to ensure positive treatment outcomes for MCPs.12,14 Addressing the unique oral health needs for the MCP population is of high importance. With a focus on the oral health needs of MCPs who utilize the ODSC and in an effort to improve patient services and access to care, the investigators
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of this study initiated this research effort. Therefore, the purpose of this study was to identify predictors and/or factors associated with MCPs seeking dental care at an urban university dental school setting specifically the ODSC at the UMKC SOD.
were included. The survey instrument was modified using a multi-step process with several levels of checks and balances to review the customized survey. The instrument was adapted by individuals from the UMKC SOD with survey expertise and included consultation with additional faculty at the UMKC SOD.
Met h od s
Data collection
Research design An 18-item survey instrument was developed to identify predictors and/or factors associated with MCP seeking dental care at the ODSC at the UMKC SOD.
Subjects/study population This study employed a census design of new patients who utilized the ODSC at the UMKC SOD for their oral health needs during a 5-year period from 2006 to 2011. The study population was identified by using the SOD’s Computer Management System (CMS) from patients who sought oral health care in the ODSC during the 5-year time frame. To generate the mailing list for this study, all new patients to the ODSC from the 5 years indicated above at the UMKC SOD were included. The CMS data were accessed to include January 1, 2006 up to and including December 31, 2011. To the best of the investigator’s efforts, inactive deceased patients’ names were removed (by UMKC administrative personnel not associated with this study) before the address list was generated. This study did not include patients who were less than 18 years old at the time the questionnaire was mailed.
Survey instrument A previous survey developed by Heaton et al.19 was utilized as a guide to construct the survey questions developed for this study. The Heaton instrument was used because it was the best fit for this study and was tested for internal validity and reliability. Survey questions requested information regarding demographics, reasons for utilizing the ODSC at the UMKC SOD, self-rated medical and dental health, frequency of past dental care, and perceived dental needs
After approval was obtained from the Social Sciences Institutional Review Board (SSIRB) at UMKC (Protocol #SS11–172X: exempt status), the CMS system at the UMKC SOD was accessed for addresses of those patients seeking oral health care who were new to the ODSC within the 5-year period identified from 2006 to 2011. The initial mailing included a cover letter; an 18-item survey and a prepaid return envelope. Every reasonable effort was made to maintain confidentiality and anonymity of the participants during this study to ensure there was no way to re-identify the participant and link the respondent back to the completed survey. Administrative personnel (not the investigators) identified the target population from the ODSC via the CMS and after removing deceased patient’s from the list, provided the final number of patients eligible to be surveyed (N = 2,541). The investigators did not have access to any personal identifying patient information (names and addresses); only administrative personnel (as described earlier) had access to patient names and addresses. The primary investigator and other investigators were not shown or involved in development of the mailing list. Survey recipients were directed not to identify themselves in any way on the survey or return mailing. Names and addresses were ink-jetted on the envelopes and postcards and the investigators were not involved in any part of this process. The surveys were returned to UMKC main mailing address and then forwarded to the UMKC SOD ODSC. A follow-up postcard was mailed to each participant 3 weeks after the initial mailing. After the follow-up postcards were mailed, a 2 week cut-off date was established and no more data were
Oral health care in oncology dental support clinic
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R es ul t s
Table 1. Demographic characteristics of respondents. Demographic characteristics
Category
Age range
Sex Ethnicity
Highest level of education completed
Total household income
Frequency
Percent
18–30 years old
16
3.6%
31–40 years old
14
3.1%
41–50 years old
43
9.7%
51–60 years old
126
28.3%
61–70 years old
138
31.0%
71 years or older
108
24.3%
Female
232
52.3%
Male
212
47.7%
Mexican American
9
2.0%
Other Hispanic
6
1.4%
Non-Hispanic Caucasian
367
83.4%
Non-Hispanic African American
48
10.9%
Other race-including multi-racial
10
2.3%
Less than high school
20
4.5%
High school
94
21.2%
More than high school
330
74.3%
Less than $10,000
49
11.8%
$10,000–$19,000
66
15.9%
$20,000–$29,000
49
11.8%
$30,000–$39,000
43
10.4%
$40,000–$49,000
36
8.7%
More than $50,000
171
41.3%
Valid percentages were reported in Tables 1–3. Valid percentage excludes all nonresponses and identifies the percentages only among the participants who answered the question.
accepted after this date. To ensure the highest response rate for this study, traditional mailed surveys were used instead of electronic correspondence. Since not everyone has access to a computer or internet and patients are not traditionally contacted via electronic correspondence at the UMKC SOD, the investigators determined e-mail communication for contacting patients would be limited and may not have reached the desired population for this study.
Statistical analysis An exploratory analysis that included descriptive statistics of percentages and frequencies were used to evaluate the survey data in each of the following categories: demographics, reasons for utilizing the ODSC at the UMKC SOD,
Corrigan et al.
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self-rated medical and dental health, frequency of past dental care, and perceived dental needs. Pearson’s chi-squared test was used to assess the primary medical diagnoses by gender. Also, the relationship between self-rated dental health and specific variables, such as household income, importance of receiving dental care, age, and gender was examined using a chi-square analysis. A logistic regression model was applied to investigate the relationship between the primary medical diagnoses and the actual health status with overall health and dental health. A statistical software program (Statistical Package for the Social Sciences [SPSS version 19.0, IBM inc., Chicago, IL, USA]) was used to complete the analyses. The α-value used for this study was α = 0.05.
Traditional mailed surveys were sent to 2,541 study participants, which yielded a response rate of approximately 18% (450 surveys). An additional 28 surveys were received but not used in the final analysis based on the inclusion/exclusion criteria. Surveys completed by the respondent and/or a care giver on their behalf (8.7%) were included.
Demographics Based on descriptive statistical analyses, Table 1 provides an overview of the demographic characteristics of the respondents who completed the survey. Questions regarding age, sex, ethnicity, education, and income were included. Individuals in the age range of 61–70 years old generated the highest response rate (31.0%). Female to male respondents were comparable at 52.3% and 47.7%, respectively. The majority of respondents identified their ethnicity as non-Hispanic Caucasian (83.4%) with an education level beyond high school (74.3%). Total household income levels ranged from less than $10,000 (11.8%) to more than $50,000 (41.3%) annually.
Reasons for utilizing the ODSC The majority of patients (76.3%) indicated a referral from their medical provider was the main reason they chose the ODSC for their oral health care needs. Other responses indicated the availability of dental specialists on site (21.2%) and more affordable treatment (20.3%) were reasons to seek care at the ODSC. Additionally, some patients reported they sought care in the ODSC because they had none or limited money for treatment (9.7%) or because they could not get an appointment at any other dental clinic (2.3%). Timely treatment was only recognized by a small number of patients (5.9%) as a reason for choosing the ODSC for their dental needs. Other selfreported reasons (13.5%) patients sought care in the ODSC included: “special X-rays for oral surgeon,” “unique CT scan technology,” “discounted services easier on budget,” “unknown,” and “availability of scanning equipment.”
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Table 2. Primary medical diagnoses reported according to gender. Female
Male
Percent
p-value
Cancer
100
119
50.0%
.005*
Organ transplant (kidney or liver)
18
19
8.3%
.635
Bone marrow transplant
1
8
2.0%
.012*
HIV-AIDS
0
3
0.7%
.068
Medical diagnosis
Hepatitis Other self-reported responses not included above
3
4
1.6%
.611
122
71
43.5%
ARTICLE ABSTRACT The purpose of this study was to identify predictors and/or factors associated with medically compromised patients seeking dental care in the oncology dental support clinic (ODSC) at the University of Missouri-Kansas City (UMKC) School of Dentistry. An 18-item survey was mailed to 2,541 patients who were new patients to the clinic from 2006 to 2011. The response rate was approximately 18% (n = 450). Analyses included descriptive statistics of percentages/frequencies as well as predictors based on correlations. Fifty percent of participants, 100 females and 119 males, identified their primary medical diagnosis as cancer. Total household income (p < .001) and the importance of receiving dental care (p < .001) were significant factors in relation to self-rated dental health. Perceived overall health (p < .001) also had a significant association with cancer status and the need for organ transplants. This study provided the ODSC at UMKC and other specialty clinics with vital information that can contribute to future planning efforts.
KEY WORDS: Oncology dental support clinic, oral health
Factors influencing patients seeking oral health care in the oncology dental support clinic at an urban university dental school setting Dale M. Corrigan, RDH, MS;1 Mary P. Walker, DDS, PhD;2 Ying Liu, PhD;3 Tanya Villalpando Mitchell, RDH, MS4* 1Graduate
Dental Hygiene Student; 2Associate Dean for Research and Graduate Programs; Assistant Professor Research and Graduate Programs; 4Associate Professor and Director Graduate Studies Division of Dental Hygiene, University of Missouri-Kansas City School of Dentistry, Kansas City, Missouri. *Corresponding author e-mail: [email protected] 3Clinical
Spec Care Dentist 34(3): 106-113, 2014
Scient if ic a r t icl e cont ent
With a focus on health promotion and disease prevention, the U.S. Department of Health and Human Services (HHS) in 2000 initiated Oral Health in America: A Report of the Surgeon General. The main objective of this initiative is to “improve quality of life and eliminate health disparities by facilitating collaborations among individuals, health care providers, communities, and policymakers at all levels of society and by taking advantage of existing initiatives.”1 Oral health is an essential element to overall general health and quality of life. It is inappropriate to view oral health and general health as separate conditions because they are truly interdependent and one cannot occur without the other.1,2 The Healthy People 2020 initiative was developed with consideration from several previous projects that included the 1979 Surgeon General’s Report, Healthy People 1990, 2000, and 2010.2 The goal as a nation and the emphasis for 2020 is placed on formulating a plan to concentrate on reducing and eliminating health disparities in an effort to obtain health equity. As part of the 2020 topics and objectives, treatment and prevention goals for cancer are specifically addressed. The underlying focus for cancer is to reduce the number of new cases, minimize illnesses associated with the disease, disability, and decrease the number of deaths. It is important to note that decreasing known risk factors,
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receiving proper vaccinations such as those designed to prevent the hepatitis B virus and the human papillomavirus (HPV) and obtaining recommended screenings can all be utilized as appropriate measures to help prevent cancer.2
Med ica l ly c o m p r o m i se d p a t ient s
Cancer is ranked among the top two leading causes of all deaths in the United States (U.S.), trailing heart disease by only 2%.3 A recent report published by the American Cancer Society (ACS) predicted the diagnosis rate of new cancer cases in the U.S. would exceed
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12037
26/03/14 9:09 AM
O R A L H E A LT H C A R E I N O N C O L O G Y D E N TA L S U P P O R T C L I N I C
approximately 1.6 million in 2012.4 Specifically, cancers affecting the oral cavity and pharynx (including the tongue, mouth, pharynx, and other areas of the oral cavity) in both men and women are estimated to account for 40,250 of new cancer cases.4 Recently, the demographic picture for developing oral cancer has changed significantly due to identification of the HPV-16 virus as a contributory factor in the prevalence of cancers in the posterior areas of the mouth (oropharynx).5 This turn of events is of particular importance in regard to oral health and a disease once thought to predominantly affect an aging population. This change in disease demographics reinforces the value of focusing on prevention.2 With a rise in the elderly population and more people in need of organ transplants, there is a greater need to provide specialty oral health care for this medically compromised population.6 Kidney transplants are one of the most common organ transplant procedures performed in the United States. According to the Organ Procurement and Transplantation Network (OPTN), there were 316,493 kidney transplants performed in the U.S. from January 1, 1988 to November 30, 2011.7 As part of the healthcare community, oral health care providers are encouraged to screen patients for high blood pressure during dental visits.8,9 Monitoring blood pressure levels on a regular basis can help determine whether or not patients are maintaining a controlled blood pressure. This is a key factor in treating chronic kidney disease.10 As the numbers continue to increase in regard to the prevalence of oral cancer and end stage renal disease (ESRD), there is a higher probability that oral healthcare providers may encounter patients who are medically compromised. Because of the obvious inherent challenges with this patient population, it is imperative to understand that the complexities of certain medical treatments can be as traumatic as the effects of the disease itself. When providing oral health services to medically compromised patients (MCP), the role of the oral healthcare
Corrigan et al.
scd12037.indd 107
provider is to help guard against further complications due to an already compromised immune system.6,11 With an increased awareness of the difficulties associated with treating the oral health needs of MCP, the value of a dental professional as part of the health team is enhanced. As presented in the Surgeon General’s Report, “oral health is not a given,” it requires a continuous multi-faceted plan and unified approach from the community, caregivers, patients, and healthcare providers. Undoubtedly, well trained dental professionals play a significant role in the movement toward obtaining overall health. Consideration of treatment modalities for MCP should be based on the individual needs of the patient, whether care is provided in a private office setting, community outreach program, or dental school setting. In regard to providing specialized oral healthcare, the importance of educating dental professionals to treat MCP cannot be understated. Realizing this need, the University of Missouri-Kansas City (UMKC) School of Dentistry (SOD) has taken a first step in addressing this issue through establishment and continuity of the oncology dental support clinic (ODSC).
De nt a l ed uca t iona l e xpe r iences
To help improve treatment outcomes for MCPs, it is imperative to provide the appropriate didactic education for dental and dental hygiene students. It is important to create opportunities to treat patients with special needs in a clinical setting as well.12 The curriculum and training components of dental and dental hygiene programs must take into consideration the special needs population in order to help address their underserved dental needs. Incorporating educational and clinical experiences into current educational programs would make a significant difference in servicing the oral health needs of MCP.13-15 This approach also prepares the dental and allied dental hygiene students to treat MCPs upon
graduation from their respective programs. The Commission on Dental Accreditation (CODA) adopted accreditation standards for dental educational programs as defined in Standard 2-Educational Programs in August 2010. Specifically, standard 2–23b (screening and risk assessment for head and neck cancer), 2–24 (assessing treatment need of patients with special needs), and 2–25 (provide opportunities and encourage students to engage in service learning and/or community-based learning experiences) are designed to decrease oral health disparity and address issues related to special patient care (SPC).16 On the forefront of these recommendations, dental schools in New York, West Virginia, Washington, Louisville, Ohio, Florida, and New Jersey have implemented programs aimed at providing care for special patient populations.15 In these schools, the programs are designed to concentrate on developmentally disabled (DD) individuals. There are many complex factors associated with a university based special patient care clinic (SPCC) whether serving DD and/ or MCPs. Dehaitem et al.13 investigated dental hygiene curriculums in the U.S. to see if the programs provided educational opportunities to students in regard to treating special needs patients. Of the 101 schools that responded to the survey, all programs reported they at least touch on this information in the classroom setting. However, less than half of the programs (42%) made the requirement for students to provide treatment to special needs patients within a clinical setting. The remaining dental hygiene programs (56.9%) did not require students to acquire clinical experience in this area. In a study conducted by Vainio et al.14 dental students’ educational experiences, attitudes, and behaviors regarding SPC were examined. Students reported the value in receiving a quality education with a focus on treatment of patients with special needs, leads to more confident attitudes and behaviors when providing patient care. At the UMKC SOD, dental
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and dental hygiene students are given this opportunity through participation in a practicum within the ODSC. The ODSC at the UMKC SOD was originally named the SPCC. It began in 1989 with its purpose of providing educational opportunities for dental and dental hygiene students to learn about the oral complications associated with cancer treatments. As part of their academic experience, undergraduate dental students and practicum dental hygiene students participate in rotations as part of their clinical courses. The ODSC has since served as a clinic where dental evaluations are performed for head and neck cancer patients in the Kansas City and surrounding areas prior to their cancer treatments. In addition, the ODSC provides dental services to a variety of MCPs that includes those with cancer and patients who are in need of organ transplantation.17 Today, the clinic continues to focus on comprehensive collaborative care that includes nonsurgical periodontal therapies, extensive restorative procedures (restorations, crowns, and bridges), removable prosthodontics, and fabrication of intraoral positioning devices used during radiotherapy. A study completed by Schwenk et al.18 identified whether or not a dental school had a separate clinic area to provide oral health care for their patients with special needs. Based on the response to the survey, 40% (17/42) of dental schools reported they had a specific area to treat patients with special needs. This is also true of the ODSC at the UMKC SOD. The majority of the dental schools (41/42) with a SPCC reported they treated patients who were medically compromised. Enhanced education and increased research efforts should be an integrated process employed to ensure positive treatment outcomes for MCPs.12,14 Addressing the unique oral health needs for the MCP population is of high importance. With a focus on the oral health needs of MCPs who utilize the ODSC and in an effort to improve patient services and access to care, the investigators
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of this study initiated this research effort. Therefore, the purpose of this study was to identify predictors and/or factors associated with MCPs seeking dental care at an urban university dental school setting specifically the ODSC at the UMKC SOD.
were included. The survey instrument was modified using a multi-step process with several levels of checks and balances to review the customized survey. The instrument was adapted by individuals from the UMKC SOD with survey expertise and included consultation with additional faculty at the UMKC SOD.
Met h od s
Data collection
Research design An 18-item survey instrument was developed to identify predictors and/or factors associated with MCP seeking dental care at the ODSC at the UMKC SOD.
Subjects/study population This study employed a census design of new patients who utilized the ODSC at the UMKC SOD for their oral health needs during a 5-year period from 2006 to 2011. The study population was identified by using the SOD’s Computer Management System (CMS) from patients who sought oral health care in the ODSC during the 5-year time frame. To generate the mailing list for this study, all new patients to the ODSC from the 5 years indicated above at the UMKC SOD were included. The CMS data were accessed to include January 1, 2006 up to and including December 31, 2011. To the best of the investigator’s efforts, inactive deceased patients’ names were removed (by UMKC administrative personnel not associated with this study) before the address list was generated. This study did not include patients who were less than 18 years old at the time the questionnaire was mailed.
Survey instrument A previous survey developed by Heaton et al.19 was utilized as a guide to construct the survey questions developed for this study. The Heaton instrument was used because it was the best fit for this study and was tested for internal validity and reliability. Survey questions requested information regarding demographics, reasons for utilizing the ODSC at the UMKC SOD, self-rated medical and dental health, frequency of past dental care, and perceived dental needs
After approval was obtained from the Social Sciences Institutional Review Board (SSIRB) at UMKC (Protocol #SS11–172X: exempt status), the CMS system at the UMKC SOD was accessed for addresses of those patients seeking oral health care who were new to the ODSC within the 5-year period identified from 2006 to 2011. The initial mailing included a cover letter; an 18-item survey and a prepaid return envelope. Every reasonable effort was made to maintain confidentiality and anonymity of the participants during this study to ensure there was no way to re-identify the participant and link the respondent back to the completed survey. Administrative personnel (not the investigators) identified the target population from the ODSC via the CMS and after removing deceased patient’s from the list, provided the final number of patients eligible to be surveyed (N = 2,541). The investigators did not have access to any personal identifying patient information (names and addresses); only administrative personnel (as described earlier) had access to patient names and addresses. The primary investigator and other investigators were not shown or involved in development of the mailing list. Survey recipients were directed not to identify themselves in any way on the survey or return mailing. Names and addresses were ink-jetted on the envelopes and postcards and the investigators were not involved in any part of this process. The surveys were returned to UMKC main mailing address and then forwarded to the UMKC SOD ODSC. A follow-up postcard was mailed to each participant 3 weeks after the initial mailing. After the follow-up postcards were mailed, a 2 week cut-off date was established and no more data were
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R es ul t s
Table 1. Demographic characteristics of respondents. Demographic characteristics
Category
Age range
Sex Ethnicity
Highest level of education completed
Total household income
Frequency
Percent
18–30 years old
16
3.6%
31–40 years old
14
3.1%
41–50 years old
43
9.7%
51–60 years old
126
28.3%
61–70 years old
138
31.0%
71 years or older
108
24.3%
Female
232
52.3%
Male
212
47.7%
Mexican American
9
2.0%
Other Hispanic
6
1.4%
Non-Hispanic Caucasian
367
83.4%
Non-Hispanic African American
48
10.9%
Other race-including multi-racial
10
2.3%
Less than high school
20
4.5%
High school
94
21.2%
More than high school
330
74.3%
Less than $10,000
49
11.8%
$10,000–$19,000
66
15.9%
$20,000–$29,000
49
11.8%
$30,000–$39,000
43
10.4%
$40,000–$49,000
36
8.7%
More than $50,000
171
41.3%
Valid percentages were reported in Tables 1–3. Valid percentage excludes all nonresponses and identifies the percentages only among the participants who answered the question.
accepted after this date. To ensure the highest response rate for this study, traditional mailed surveys were used instead of electronic correspondence. Since not everyone has access to a computer or internet and patients are not traditionally contacted via electronic correspondence at the UMKC SOD, the investigators determined e-mail communication for contacting patients would be limited and may not have reached the desired population for this study.
Statistical analysis An exploratory analysis that included descriptive statistics of percentages and frequencies were used to evaluate the survey data in each of the following categories: demographics, reasons for utilizing the ODSC at the UMKC SOD,
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self-rated medical and dental health, frequency of past dental care, and perceived dental needs. Pearson’s chi-squared test was used to assess the primary medical diagnoses by gender. Also, the relationship between self-rated dental health and specific variables, such as household income, importance of receiving dental care, age, and gender was examined using a chi-square analysis. A logistic regression model was applied to investigate the relationship between the primary medical diagnoses and the actual health status with overall health and dental health. A statistical software program (Statistical Package for the Social Sciences [SPSS version 19.0, IBM inc., Chicago, IL, USA]) was used to complete the analyses. The α-value used for this study was α = 0.05.
Traditional mailed surveys were sent to 2,541 study participants, which yielded a response rate of approximately 18% (450 surveys). An additional 28 surveys were received but not used in the final analysis based on the inclusion/exclusion criteria. Surveys completed by the respondent and/or a care giver on their behalf (8.7%) were included.
Demographics Based on descriptive statistical analyses, Table 1 provides an overview of the demographic characteristics of the respondents who completed the survey. Questions regarding age, sex, ethnicity, education, and income were included. Individuals in the age range of 61–70 years old generated the highest response rate (31.0%). Female to male respondents were comparable at 52.3% and 47.7%, respectively. The majority of respondents identified their ethnicity as non-Hispanic Caucasian (83.4%) with an education level beyond high school (74.3%). Total household income levels ranged from less than $10,000 (11.8%) to more than $50,000 (41.3%) annually.
Reasons for utilizing the ODSC The majority of patients (76.3%) indicated a referral from their medical provider was the main reason they chose the ODSC for their oral health care needs. Other responses indicated the availability of dental specialists on site (21.2%) and more affordable treatment (20.3%) were reasons to seek care at the ODSC. Additionally, some patients reported they sought care in the ODSC because they had none or limited money for treatment (9.7%) or because they could not get an appointment at any other dental clinic (2.3%). Timely treatment was only recognized by a small number of patients (5.9%) as a reason for choosing the ODSC for their dental needs. Other selfreported reasons (13.5%) patients sought care in the ODSC included: “special X-rays for oral surgeon,” “unique CT scan technology,” “discounted services easier on budget,” “unknown,” and “availability of scanning equipment.”
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Table 2. Primary medical diagnoses reported according to gender. Female
Male
Percent
p-value
Cancer
100
119
50.0%
.005*
Organ transplant (kidney or liver)
18
19
8.3%
.635
Bone marrow transplant
1
8
2.0%
.012*
HIV-AIDS
0
3
0.7%
.068
Medical diagnosis
Hepatitis Other self-reported responses not included above
3
4
1.6%
.611
122
71
43.5%
