Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 360–365 doi: 10.1111/adj.12197
Transitioning of special needs paediatric patients to adult special needs dental services GL Borromeo,* G Bramante,* D Betar,* C Bhikha,* YY Cai,* C Cajili* *Melbourne Dental School, The University of Melbourne, Victoria.
ABSTRACT Background: Special needs dentistry is in its infancy compared to other dental specialties. Continuity of care through transition from paediatric to adult dental care providers is unknown. This study seeks to determine the nature of transition practices adopted by paediatric and special needs (SN) specialists practising throughout Australia. Methods: A survey was sent to all paediatric and SN specialist dentists in Australia to determine the nature of current transition practices for paediatric SN patients in Australia. Two subsequent mail-outs were sent to non-responders. Results: Forty-nine specialist dentists registered across Australia completed the survey, of which 35 (71%) were paediatric dentists and 14 (29%) were SN dentists. Both paediatric and SN dentists treated patients over the age of 18. Of the total paediatric dentists who had transition discussions with their paediatric patients and their families, the majority (over 80%) discussed treatment options available as part of future oral care management. Paediatric dentists identified level of independence and financial situations as the most significant barrier for transition. Conclusions: Key factors exist that should be discussed with SN patients and their parents and/or guardians in order to enhance the prospect of sustained dental care into adulthood. Keywords: Dentistry, paediatric dentistry, special needs dentistry, transition. Abbreviations and acronyms: SN = special needs; SND = special needs dentistry. (Accepted for publication 21 November 2013.)
INTRODUCTION In Australia, special needs dentistry (SND) is defined as the dental specialty concerned with the oral health of people with an intellectual disability, medical, physical or psychiatric conditions that require special methods or techniques to prevent or treat oral health problems.1 In 2008 approximately 2% of adolescents aged between 15 and 19 years had severe and profound disability requiring special health care needs.2 Moreover, the 2003 National Oral Health Plan estimated by 2009, 20% of the population would be classified as disabled.2,3 With poorer oral health status also being universally reported in the special needs (SN) population, there is an increased urgency to address the oral health deficiencies endured by this cohort.3–7 Population based surveys indicate dental care is the most common unmet health care need of SN children with treatment for general health conditions taking precedence over oral health care.8–10 Studies indicate successful transition from paediatric to adult oriented care has the greatest impact on continuity of care and improved long-term health out360
comes of SN patients.11–14 Furthermore, over the past 30 years the vast majority of SN children with chronic conditions that would require specialist dental care will live well into adulthood.15,16 Consequently, the transition from paediatric to adult dental services has become an increasingly important stage to ensure continuity of care in adult years. However, few studies have specifically investigated the transition pathways adopted by SN adolescents as they seek care from adult oral health care providers. Only one comprehensive study aimed at understanding the transition pathways of adolescents with and without special oral health care needs is currently available in the scientific literature.15 The extent and impact of similar support services adopted by paediatric dentists in Australia is unclear. The transition process is not without challenges and can often lead to a discontinuity of care and neglect in an already vulnerable population. Population based surveys have cited inadequate and belated preparation, economic challenges, communication difficulties and lack of adequately trained adult service providers as the primary barriers to successful transition.9,12,17 © 2014 Australian Dental Association
Special needs paediatric to adult dental services Moreover, although identifying a need to better manage SN transition, there is a distinct lack of guidelines or polices from dental associations and boards that would facilitate the transitioning process in both public and private sectors.18,19 With SND in its relative infancy compared to other dental specialties, there is a pressing demand to facilitate continuity of care through transition of patients from paediatric to adult dental care providers. The aim of this study was to determine the nature of transition practices adopted by paediatric and SN specialists practising throughout Australia. An appraisal of current practices may help identify appropriate measures to minimize the impact of known barriers associated with successful transition and enhance the prospect of sustained oral health maintenance in this patient cohort. MATERIALS AND METHODS Postal surveys were distributed to all paediatric (n = 61) and SN specialist dentists (n = 14) in Australia. They were surveyed to determine the nature of current transition practices for paediatric SN patients in Australia. The survey was divided according to clinician demographics including gender, age, year of graduation, years in specialist practice and practice location; category of SN patient treated and transition practices including transition discussion and criteria, barriers, methods for transition and follow-up procedures. Two subsequent mail-outs were sent to nonresponders. All surveys were returned in a de-identified, coded format. Ethics approval Ethics approval was obtained from the University of Melbourne Human Research Ethics Committee (HREC no. 1136614). Data analysis Data analysis consisted of chi-squared regression analysis or Fisher’s exact test using the statistical software programme SPSS version 20 (IBM Corporation, New York, USA) with significance taken as p < 0.05. RESULTS Study participants A total of 51 surveys were returned accounting for a 68% response rate. Two participants returned a blank survey because they were no longer in clinical practice. Hence 49 specialist dentists registered across Australia completed the survey, of which 36 (74%) © 2014 Australian Dental Association
were paediatric dentists and 13 (27%) were SN dentists. Over 90% of all practitioners surveyed were trained in Australia, 70% were over 40 years of age and more than 80% graduated prior to 1999. The practising location of paediatric and SN dentists was not significantly different across all Australian states (p-value = 0.63; v2 = 5.44). Most paediatric dentists practised in New South Wales (37%) and Victoria (26%) followed by South Australia (14%), Queensland (11%) and Western Australia (11%). The majority of SN dentists practised in Victoria (43%), followed by South Australia (29%), New South Wales (14%) and Queensland (14%). There were no registered SN dentists in Western Australia, Tasmania or the Australian Capital Territory. Maximum treatment age for clinicians Both paediatric and SN dentists treated patients over the age of 18. There was no significant difference in the number or specialty of clinicians treating nonSND patients over the age of 18 (p-value = 0.21; Fisher’s exact test) with 20% of paediatric dentists and 36% of SN dentists treating these patients. There was no significant difference in the number and type of clinicians treating SN patients over 18 years of age with 66% of paediatric dentists and all SN dentists managing patients in this age cohort (p-value = 0.59; Fisher’s exact test). Subcategory of paediatric special needs patients All clinicians regardless of specialty treated medically compromised paediatric patients (p-value = 0.005; Fisher’s exact test), had psychological or behavioural problems (p-value = 0.001; Fisher’s exact test), or an intellectual (p-value < 0.001; Fisher’s exact test), or physical disability (p-value < 0.001; Fisher’s exact test). Treatment of paediatric patients with an infectious disease was variable, with 71% of paediatric dentists and 29% of SN dentists treating this group (p-value = 0.007; Fisher’s exact test). Transition practices of paediatric dentists Of the total paediatric dentists who had transition discussions with their paediatric patients and their families, the majority (over 80%) discussed treatment options available as part of future oral care management. Oral hygiene was the most discussed feature and a single financial option the least discussed (Fig. 1). When financial options were discussed with transitioning patients, multiple financial options were more frequently discussed rather than any one single option. These options included a combination of private health insurance, government grants, enhanced 361
GL Borromeo et al.
Fig. 1 Factors discussed between paediatric dentists and their patients, families and carers during the transition process. Financial options refers to whether this was discussed with patients (yes/no). If the specialist dentists only recommended a single financial option this was recorded under this category. If, however, multiple financial options were discussed this was recorded under this category. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems.)
Fig. 2 Barriers identified by paediatric dentists as potentially impeding the transition process of paediatric special needs patients into adult services. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems.)
primary care schemes and on occasion, private loans to cover potential future oral health maintenance costs. Barriers to transition identified by paediatric dentists Paediatric dentists identified level of independence and financial situations as the most significant barrier for transition in most SN categories, except for those with a medically compromised issue. Level of maturity was considered more so if the patient had a psychological or behavioural problem (Fig. 2). Paediatric dentists when initiating the transition process used multiple criteria. However, age was the most selected criteria regardless of the SN category involved (Fig. 3). Where paediatric dentists felt patients should be transitioned, method of referral and follow-up process Paediatric dentists were asked if they would transition their patients to a general dentist or a specialist dentist. General dentists were selected half as often as SN dentists (20% versus 40%). Between 40% and 48% of paediatric dentists did not specify which clinician they would refer to, suggesting either an SN dentist or general dentist would be a suitable option. In terms of the method of referral, most paediatric dentists provided a written referral regardless of the SN category (Fig. 4). Verbal referrals were used in less 362
Fig. 3 Criteria used by paediatric dentists to initiate the transition process. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems.)
than 13% of cases (Fig. 4). In some categories no referral was provided. Thirty-two per cent of paediatric dentists reported following up referrals. They were more likely to follow up the referral process when referring to an SN dentist (60%) as opposed to when the referral was made to a general dentist (42%). DISCUSSION The current study aimed to understand the nature of transition practices from the perspective of paediatric © 2014 Australian Dental Association
Special needs paediatric to adult dental services
Fig. 4 Method of referral used by paediatric dentists during the transition process. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems).
dentists practising throughout Australia. The importance of transition cannot be overlooked with a 2006 US national survey of children with special health care needs reporting more than 81% of SN children required preventive dental care and 24% needing additional more complex treatment in the preceding 12 months. Moreover, just under 11% of children approaching likely transition age had unmet dental care needs other than preventive treatment.10 In Australia, a small cross-sectional study on SN children in developmental and special schools reported similar unmet dental needs in the SN children population. In the study 91% had preventive and restorative dental needs, where 50% were considered moderate to complex treatments.4 Other studies further suggest that unmet dental health care needs are higher for children with SN compared to the general child population and this trend is more strongly reflected in adult life.5,8,10,20 These studies suggest a detrimental effect on continuity of care as SN children transition to adult providers, a finding previously reported for general health conditions.14 However, the impact on unmet dental needs that transition and the specific transition pathways taken up by SN children have not been a specific research focus. Successful transition has often been associated with numerous barriers, ranging from access to services, inadequate preparation, an unidisciplinary focus and financial limitations that often preclude the long-term maintenance of oral health service provision.21–23 Identification of limitations in current practices is paramount in identifying new approaches to aid in successful transition of adolescent special needs patients to appropriate adult oriented care. An extensive crosssectional survey of paediatric dentists in the United States assessed the extent transition support services were being utilized by paediatric dentists.15 It was found only 13% of respondents had staff members © 2014 Australian Dental Association
dedicated to facilitate transition of children with SN. Nevertheless, just over 50% assisted in referral of patients to a general dentist or specialist, while additional support by providing a history and summary for the patient only occurred in 58% of practices.15 This is supported in the current study where similar numbers provided such written referrals. It was also evident in the present study that follow-up with the post referral was important. Special needs dentistry is defined as the dental specialty concerned with the oral health of adults with an intellectual disability, medical, physical, infectious or psychiatric conditions that require special methods or techniques to prevent or treat oral health problems.1,24 Paediatric dentists, on the other hand, manage patients up to the end of their adolescent years as seen in their scope of practice.24,25 Historically, paediatric dentists managed such patients well into adult years.15,16 This is supported in the present study where a high proportion of paediatric dentists reporting managing adult SN patients. With the development of SND as a specialty, management of patients beyond 18 years of age is shifting away from the paediatric dentist. This was reflected in the current study where all SN specialists managed adult patients compared to less than two-thirds of paediatric dentists. The shift to a different specialty dental group is gradual as seen here where only 13 SN dentists were surveyed consisting of the total population of these dentists across Australia. This is in line with worldwide trends in this specialty.26 This then creates problems in terms of a shortage in the SN workforce and a concentration of low specialist numbers centred on major cities and in localities associated with academic training.26 This was evident in the present study with most SND specialists in Victoria and South Australia, the two states with the largest SND training facilities at undergraduate, graduate and postgraduate levels. The relative shortage of suitably qualified specialists and the scope of practice of paediatric dentists has led to the development of a significant barrier in the management of SN patients.8,17 Both small specialist numbers and a geographically and technically skewed workforce would limit future adequate transition of SN patients between paediatric and SN dentists. Discontinuity of health care, in particular oral health care, is a common outcome following transition from paediatric to adult oriented services. Population based surveys have suggested inadequate and belated preparation, economic challenges and poor inter-disciplinary communication represent the primary barriers to successful transition.9,12,17 The current study showed preparation by paediatric dentists occurred and involved discussions regarding treatment options, importance of maintaining oral hygiene practices and financial options. 363
GL Borromeo et al. Preparation for transition has been highlighted as a simple, effective means to improve transition outcomes. Kennedy et al. demonstrated that awareness and understanding of the eventual need to transition to adult services was more likely to result in successful transition.27 Additionally, early introduction to the concept of transition has been correlated with successful transition.28,29 It remains to be determined at what stage these preparatory practices are occurring and whether the impact on successful transition is favourable. Discussions regarding oral health education and potential treatment options would improve patient and/or carer oral health awareness, which would ultimately help ensure oral health remains on the agenda of multidisciplinary health management of SN patients, especially when studies indicate general medical considerations often take precedence.30–32 Financial considerations, whilst not criteria used by paediatric dentists during the transition process, were considered a barrier and a challenge when looking to facilitate transition. Studies have shown limited government funded financial support directed towards oral health favours the adoption of private insurance schemes.22,33 However, comprehensive cover is often lacking and inadequate in the context of oral health service provision.34 Moreover, there are limited viable alternatives for practitioners to suggest to their patients. In Australia, recent Commonwealth Government budget reforms have rendered the Chronic Disease Dental Scheme, which was set up to assist SN patients, a redundant form of public health policy from 1 December 2012.35 A replacement policy that could provide financial aid for dental treatment of SN adults has not yet been provided. The implication of neglecting the financial burden in facilitating transition may impact negatively on continuity of care, particularly exacerbated in those with special needs.36 Paediatricians are reported to consider the level of independence as the most significant barrier to transition of SN patients to adult oriented care.36 This was also indicated by SN dentists, who considered this on par with financial implications and above the level of maturity and age related barriers. The belief that multiple barriers to transition exist, as seen in this study, further demonstrates the delicate and complex nature of transition in the SN sector. Age was the criteria used by most paediatric dentists as the catalyst for transition of SN patients. The notion of the ageing out of paediatric services is a trend consistently reported in literature regarding criteria for initiating transition of paediatric patients.37 However, particularly in the context of special needs, age represents an arbitrary assessment of the individual and is a poor indicator to initiate transition. The capacity for SN patients to engage with the demands of an adult oriented health care system should take 364
precedence over age based determinants for transition. A developmental approach has been suggested that aims to understand the effects of chronic illness on adolescent development that is independent of age. Delivery of health care in an appropriate developmental context may encourage continuity of care and optimise future management by considering the increased level of independence and maturity required by adult care systems.27 Other studies show transition may be initiated with little regard to chronological age and may preferentially consider criteria such as maturity, independence and access to services.23,38 The perception that multiple criteria should form the standard in deciding to initiate transition was reinforced in the present study, more so from the perspective of SN dentists, whereas age remained the dominant criteria reported by paediatric dentists. CONCLUSIONS The nature of transition as documented by paediatric and SN dentists have been reported in this study. When considering individual SN categories including intellectually or physically disabled, medically compromised, infectious disease and psychological and behavioural conditions, no apparent differences were identified in transition related practices being undertaken in Australia. It can be concluded that key factors exist that should be discussed with SN patients and their parents and/or guardians in order to enhance the prospect of sustained dental care into adulthood. Adequate preparation and understanding of the complex issues surrounding transition of SN patients needs to be apparent to minimize the impact of identified barriers to successful transition. Future studies should be aimed at linking transition practices and outcomes of these practices to inform on the most effective strategies to help maintain optimum oral health standards in the SN population following transition. REFERENCES 1. Royal Australian College of Dental Surgeons. Special Needs Dentistry – MRACDS(SND) and FRACDS(SND) 2011. URL: ‘http://www.racds.org/RACDS/Pathways/FRACDS-SFS/SND/RA CDS_Content/Pathways/SFS/SND.aspx?hkey=76a3e211-588e-4f86-8a5f-003ada1f62c8’. Accessed 15 May 2013. 2. Australian Institute of Health and Welfare. Disability in Australia: trends in prevalence, education, employment and community living. Bulletin no. 61. Cat. no. AUS 103. Canberra: AIHW, 2008. 3. National Advisory Committee on Oral Health. Healthy mouths healthy lives. Australia’s National Oral Health Plan 2004– 2013. Adelaide: Government of South Australia on behalf of the Australian Health Ministers’ Conference, 2004. 4. Desai M, Messer LB, Calache H. A study of the dental treatment needs of children with disabilities in Melbourne. Australia. Aust Dent J 2001;46:41–50. © 2014 Australian Dental Association
Special needs paediatric to adult dental services 5. Edelstein BL, Chinn CH. Update on disparities in oral health and access to dental care for America’s children. Acad Pediatr 2009;9:415–419.
25. AAPD Policy Guidelines. Reference Manual – Overview of Paediatric Dentistry. Am Acad Paediatr Dent 2012–13;34: 2–3.
6. Pope JE, Curzon ME. The dental status of cerebral palsied children. Pediatr Dent 1991;13:156–162.
26. Gallagher JE, Fiske J. Special care dentistry: a professional challenge. Br Dent J 2007;202:619–629.
7. Spencer AJ, Davies M, Slade G, Brennan D. Caries prevalence in Australasia. Int Dent J 1994;44(4 Suppl 1):415–423.
27. Kennedy A, Sloman F, Douglass JA, Sawyer SM. Young people with chronic illness: the approach to transition. Intern Med J 2007;37:555–560.
8. Nelson LP, Getzin A, Graham D, et al. Unmet dental needs and barriers to care for children with significant special health care needs. Pediatr Dent 2011;33:29–36.
28. Alpay H. Transition of the adolescent patient to the adult clinic. Perit Dial Int 2009;29(Suppl 2):S180–182.
9. Mayer ML, Skinner AC, Slifkin RT. Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs. Paediatrics 2004;113:e109–115.
29. de Beaufort C, Jarosz-Chobot P, Frank M, de Bart J, Deja G. Transition from paediatric to adult diabetes care: smooth or slippery? Pediatr Diabetes 2010;11:24–27.
10. Lewis CW. Dental care and children with special health care needs: a population-based perspective. Acad Paediatr 2009;9: 420–426.
30. Migliorati CA, Madrid C. The interface between oral and systemic health: the need for more collaboration. Clin Microbiol Infect 2007;13(Suppl 4):11–16.
11. Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ 2004;68:23–28.
31. Rai K, Supriya S, Hegde AM. Oral health status of children with congenital heart disease and the awareness, attitude and knowledge of their parents. J Clin Pediatr Dent 2009;33:315– 318.
12. Crall JJ. Improving oral health for individuals with special health care needs. Pediatr Dent 2007;29:98–104. 13. Nowak AJ. Patients with special health care needs in paediatric dental practices. Pediatr Dent 2002;24:227–228.
32. Yoon MN, Steele CM. Health care professionals’ perspectives on oral care for long-term care residents: nursing staff, speechlanguage pathologists and dental hygienists. Gerodontology 2012;29:e525–535.
14. Simon TD, Lamb S, Murphy NA, Hom B, Walker ML, Clark EB. Who will care for me next? Transitioning to adulthood with hydrocephalus. Pediatrics 2009;124:1431–1437.
33. Callahan ST, Cooper WO. Continuity of health insurance coverage among young adults with disabilities. Pediatrics 2007;119:1175–1180.
15. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating the transition of patients with special health care needs from paediatric to adult oral health care. J Am Dent Assoc 2010;141:1351–1356.
34. Harford J, Spencer AJ. Government subsidies for dental care in Australia. Aust N Z J Public Health 2004;28:363–368.
16. Reiss J, Gibson R. Health care transition: destinations unknown. Pediatrics 2002;110:1307–1314. 17. Davis MJ. Issues in access to oral health care for special care patients. Dent Clin North Am 2009;53:169–181. 18. Dental Board of Australia. URL: ‘http://www.dentalboard.gov.au/ Search.aspx?q=special needs transition’. Accessed 15 May 2013. 19. Australian Dental Association. URL: ‘http://www.ada.org.au/ search.aspx?search=special needs transition’. Accessed 15 May 2013. 20. Oredugba FA, Perlman SP. Oral health condition and treatment needs of Special Olympics athletes in Nigeria. Spec Care Dentist 2010;30:211–217. 21. Lam PY, Fitzgerald BB, Sawyer SM. Young adults in children’s hospitals: why are they there? Med J Aust 2005;182:381–384. 22. Lotstein DS, Inkelas M, Hays RD, Halfon N, Brook R. Access to care for youth with special health care needs in the transition to adulthood. J Adolesc Health 8;43:23–29. 23. Reiss JG, Gibson RW, Walker LR. Health care transition: youth, family, and provider perspectives. Pediatrics 2005; 115:112–120. 24. Dental Council of New Zealand. Notice of Scopes of Practice and Prescribed Qualifications. URL: ‘http://www.dcnz.org.nz/ Documents/Scopes/ScopesOfPractice_Dentists.pdf’. Accessed 15 May 2013.
© 2014 Australian Dental Association
35. Australian Government. Department of Health and Ageing. Dental Health Chronic Disease Dental Scheme. URL: ‘http:// www.health.gov.au/internet/main/publishing.nsf/Content/dental+ care+services’. Accessed 15 May 2013. 36. Burdo-Hartman WA, Patel DR. Medical home and transition planning for children and youth with special health care needs. Pediatr Clin North Am 2008;55:1287–1297. 37. Fishman E. Aging out of coverage: young adults with special health needs. Health Aff (Millwood) 2001;20:254–266. 38. McManus M, Fox H, O’Connor K, Chapman T, MacKinnon J. Paediatric perspectives and practices on transitioning adolescents with special health care needs to adult health care. Available at: ‘http://www.thenationalalliance.org/pdfs/ FS6.%20Pediatric%20Perspectives%20and%20Practices%20on %20Transitioning.pdf’.
Address for correspondence: Associate Professor Gelsomina Borromeo Melbourne Dental School The University of Melbourne 720 Swanston Street Melbourne VIC 3010 Email: [email protected]
365
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 360–365 doi: 10.1111/adj.12197
Transitioning of special needs paediatric patients to adult special needs dental services GL Borromeo,* G Bramante,* D Betar,* C Bhikha,* YY Cai,* C Cajili* *Melbourne Dental School, The University of Melbourne, Victoria.
ABSTRACT Background: Special needs dentistry is in its infancy compared to other dental specialties. Continuity of care through transition from paediatric to adult dental care providers is unknown. This study seeks to determine the nature of transition practices adopted by paediatric and special needs (SN) specialists practising throughout Australia. Methods: A survey was sent to all paediatric and SN specialist dentists in Australia to determine the nature of current transition practices for paediatric SN patients in Australia. Two subsequent mail-outs were sent to non-responders. Results: Forty-nine specialist dentists registered across Australia completed the survey, of which 35 (71%) were paediatric dentists and 14 (29%) were SN dentists. Both paediatric and SN dentists treated patients over the age of 18. Of the total paediatric dentists who had transition discussions with their paediatric patients and their families, the majority (over 80%) discussed treatment options available as part of future oral care management. Paediatric dentists identified level of independence and financial situations as the most significant barrier for transition. Conclusions: Key factors exist that should be discussed with SN patients and their parents and/or guardians in order to enhance the prospect of sustained dental care into adulthood. Keywords: Dentistry, paediatric dentistry, special needs dentistry, transition. Abbreviations and acronyms: SN = special needs; SND = special needs dentistry. (Accepted for publication 21 November 2013.)
INTRODUCTION In Australia, special needs dentistry (SND) is defined as the dental specialty concerned with the oral health of people with an intellectual disability, medical, physical or psychiatric conditions that require special methods or techniques to prevent or treat oral health problems.1 In 2008 approximately 2% of adolescents aged between 15 and 19 years had severe and profound disability requiring special health care needs.2 Moreover, the 2003 National Oral Health Plan estimated by 2009, 20% of the population would be classified as disabled.2,3 With poorer oral health status also being universally reported in the special needs (SN) population, there is an increased urgency to address the oral health deficiencies endured by this cohort.3–7 Population based surveys indicate dental care is the most common unmet health care need of SN children with treatment for general health conditions taking precedence over oral health care.8–10 Studies indicate successful transition from paediatric to adult oriented care has the greatest impact on continuity of care and improved long-term health out360
comes of SN patients.11–14 Furthermore, over the past 30 years the vast majority of SN children with chronic conditions that would require specialist dental care will live well into adulthood.15,16 Consequently, the transition from paediatric to adult dental services has become an increasingly important stage to ensure continuity of care in adult years. However, few studies have specifically investigated the transition pathways adopted by SN adolescents as they seek care from adult oral health care providers. Only one comprehensive study aimed at understanding the transition pathways of adolescents with and without special oral health care needs is currently available in the scientific literature.15 The extent and impact of similar support services adopted by paediatric dentists in Australia is unclear. The transition process is not without challenges and can often lead to a discontinuity of care and neglect in an already vulnerable population. Population based surveys have cited inadequate and belated preparation, economic challenges, communication difficulties and lack of adequately trained adult service providers as the primary barriers to successful transition.9,12,17 © 2014 Australian Dental Association
Special needs paediatric to adult dental services Moreover, although identifying a need to better manage SN transition, there is a distinct lack of guidelines or polices from dental associations and boards that would facilitate the transitioning process in both public and private sectors.18,19 With SND in its relative infancy compared to other dental specialties, there is a pressing demand to facilitate continuity of care through transition of patients from paediatric to adult dental care providers. The aim of this study was to determine the nature of transition practices adopted by paediatric and SN specialists practising throughout Australia. An appraisal of current practices may help identify appropriate measures to minimize the impact of known barriers associated with successful transition and enhance the prospect of sustained oral health maintenance in this patient cohort. MATERIALS AND METHODS Postal surveys were distributed to all paediatric (n = 61) and SN specialist dentists (n = 14) in Australia. They were surveyed to determine the nature of current transition practices for paediatric SN patients in Australia. The survey was divided according to clinician demographics including gender, age, year of graduation, years in specialist practice and practice location; category of SN patient treated and transition practices including transition discussion and criteria, barriers, methods for transition and follow-up procedures. Two subsequent mail-outs were sent to nonresponders. All surveys were returned in a de-identified, coded format. Ethics approval Ethics approval was obtained from the University of Melbourne Human Research Ethics Committee (HREC no. 1136614). Data analysis Data analysis consisted of chi-squared regression analysis or Fisher’s exact test using the statistical software programme SPSS version 20 (IBM Corporation, New York, USA) with significance taken as p < 0.05. RESULTS Study participants A total of 51 surveys were returned accounting for a 68% response rate. Two participants returned a blank survey because they were no longer in clinical practice. Hence 49 specialist dentists registered across Australia completed the survey, of which 36 (74%) © 2014 Australian Dental Association
were paediatric dentists and 13 (27%) were SN dentists. Over 90% of all practitioners surveyed were trained in Australia, 70% were over 40 years of age and more than 80% graduated prior to 1999. The practising location of paediatric and SN dentists was not significantly different across all Australian states (p-value = 0.63; v2 = 5.44). Most paediatric dentists practised in New South Wales (37%) and Victoria (26%) followed by South Australia (14%), Queensland (11%) and Western Australia (11%). The majority of SN dentists practised in Victoria (43%), followed by South Australia (29%), New South Wales (14%) and Queensland (14%). There were no registered SN dentists in Western Australia, Tasmania or the Australian Capital Territory. Maximum treatment age for clinicians Both paediatric and SN dentists treated patients over the age of 18. There was no significant difference in the number or specialty of clinicians treating nonSND patients over the age of 18 (p-value = 0.21; Fisher’s exact test) with 20% of paediatric dentists and 36% of SN dentists treating these patients. There was no significant difference in the number and type of clinicians treating SN patients over 18 years of age with 66% of paediatric dentists and all SN dentists managing patients in this age cohort (p-value = 0.59; Fisher’s exact test). Subcategory of paediatric special needs patients All clinicians regardless of specialty treated medically compromised paediatric patients (p-value = 0.005; Fisher’s exact test), had psychological or behavioural problems (p-value = 0.001; Fisher’s exact test), or an intellectual (p-value < 0.001; Fisher’s exact test), or physical disability (p-value < 0.001; Fisher’s exact test). Treatment of paediatric patients with an infectious disease was variable, with 71% of paediatric dentists and 29% of SN dentists treating this group (p-value = 0.007; Fisher’s exact test). Transition practices of paediatric dentists Of the total paediatric dentists who had transition discussions with their paediatric patients and their families, the majority (over 80%) discussed treatment options available as part of future oral care management. Oral hygiene was the most discussed feature and a single financial option the least discussed (Fig. 1). When financial options were discussed with transitioning patients, multiple financial options were more frequently discussed rather than any one single option. These options included a combination of private health insurance, government grants, enhanced 361
GL Borromeo et al.
Fig. 1 Factors discussed between paediatric dentists and their patients, families and carers during the transition process. Financial options refers to whether this was discussed with patients (yes/no). If the specialist dentists only recommended a single financial option this was recorded under this category. If, however, multiple financial options were discussed this was recorded under this category. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems.)
Fig. 2 Barriers identified by paediatric dentists as potentially impeding the transition process of paediatric special needs patients into adult services. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems.)
primary care schemes and on occasion, private loans to cover potential future oral health maintenance costs. Barriers to transition identified by paediatric dentists Paediatric dentists identified level of independence and financial situations as the most significant barrier for transition in most SN categories, except for those with a medically compromised issue. Level of maturity was considered more so if the patient had a psychological or behavioural problem (Fig. 2). Paediatric dentists when initiating the transition process used multiple criteria. However, age was the most selected criteria regardless of the SN category involved (Fig. 3). Where paediatric dentists felt patients should be transitioned, method of referral and follow-up process Paediatric dentists were asked if they would transition their patients to a general dentist or a specialist dentist. General dentists were selected half as often as SN dentists (20% versus 40%). Between 40% and 48% of paediatric dentists did not specify which clinician they would refer to, suggesting either an SN dentist or general dentist would be a suitable option. In terms of the method of referral, most paediatric dentists provided a written referral regardless of the SN category (Fig. 4). Verbal referrals were used in less 362
Fig. 3 Criteria used by paediatric dentists to initiate the transition process. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems.)
than 13% of cases (Fig. 4). In some categories no referral was provided. Thirty-two per cent of paediatric dentists reported following up referrals. They were more likely to follow up the referral process when referring to an SN dentist (60%) as opposed to when the referral was made to a general dentist (42%). DISCUSSION The current study aimed to understand the nature of transition practices from the perspective of paediatric © 2014 Australian Dental Association
Special needs paediatric to adult dental services
Fig. 4 Method of referral used by paediatric dentists during the transition process. (ID = intellectual disability; PD = physical disability; MCP = medically compromised; Inf D = infectious disease; PBP = psychological and behavioural problems).
dentists practising throughout Australia. The importance of transition cannot be overlooked with a 2006 US national survey of children with special health care needs reporting more than 81% of SN children required preventive dental care and 24% needing additional more complex treatment in the preceding 12 months. Moreover, just under 11% of children approaching likely transition age had unmet dental care needs other than preventive treatment.10 In Australia, a small cross-sectional study on SN children in developmental and special schools reported similar unmet dental needs in the SN children population. In the study 91% had preventive and restorative dental needs, where 50% were considered moderate to complex treatments.4 Other studies further suggest that unmet dental health care needs are higher for children with SN compared to the general child population and this trend is more strongly reflected in adult life.5,8,10,20 These studies suggest a detrimental effect on continuity of care as SN children transition to adult providers, a finding previously reported for general health conditions.14 However, the impact on unmet dental needs that transition and the specific transition pathways taken up by SN children have not been a specific research focus. Successful transition has often been associated with numerous barriers, ranging from access to services, inadequate preparation, an unidisciplinary focus and financial limitations that often preclude the long-term maintenance of oral health service provision.21–23 Identification of limitations in current practices is paramount in identifying new approaches to aid in successful transition of adolescent special needs patients to appropriate adult oriented care. An extensive crosssectional survey of paediatric dentists in the United States assessed the extent transition support services were being utilized by paediatric dentists.15 It was found only 13% of respondents had staff members © 2014 Australian Dental Association
dedicated to facilitate transition of children with SN. Nevertheless, just over 50% assisted in referral of patients to a general dentist or specialist, while additional support by providing a history and summary for the patient only occurred in 58% of practices.15 This is supported in the current study where similar numbers provided such written referrals. It was also evident in the present study that follow-up with the post referral was important. Special needs dentistry is defined as the dental specialty concerned with the oral health of adults with an intellectual disability, medical, physical, infectious or psychiatric conditions that require special methods or techniques to prevent or treat oral health problems.1,24 Paediatric dentists, on the other hand, manage patients up to the end of their adolescent years as seen in their scope of practice.24,25 Historically, paediatric dentists managed such patients well into adult years.15,16 This is supported in the present study where a high proportion of paediatric dentists reporting managing adult SN patients. With the development of SND as a specialty, management of patients beyond 18 years of age is shifting away from the paediatric dentist. This was reflected in the current study where all SN specialists managed adult patients compared to less than two-thirds of paediatric dentists. The shift to a different specialty dental group is gradual as seen here where only 13 SN dentists were surveyed consisting of the total population of these dentists across Australia. This is in line with worldwide trends in this specialty.26 This then creates problems in terms of a shortage in the SN workforce and a concentration of low specialist numbers centred on major cities and in localities associated with academic training.26 This was evident in the present study with most SND specialists in Victoria and South Australia, the two states with the largest SND training facilities at undergraduate, graduate and postgraduate levels. The relative shortage of suitably qualified specialists and the scope of practice of paediatric dentists has led to the development of a significant barrier in the management of SN patients.8,17 Both small specialist numbers and a geographically and technically skewed workforce would limit future adequate transition of SN patients between paediatric and SN dentists. Discontinuity of health care, in particular oral health care, is a common outcome following transition from paediatric to adult oriented services. Population based surveys have suggested inadequate and belated preparation, economic challenges and poor inter-disciplinary communication represent the primary barriers to successful transition.9,12,17 The current study showed preparation by paediatric dentists occurred and involved discussions regarding treatment options, importance of maintaining oral hygiene practices and financial options. 363
GL Borromeo et al. Preparation for transition has been highlighted as a simple, effective means to improve transition outcomes. Kennedy et al. demonstrated that awareness and understanding of the eventual need to transition to adult services was more likely to result in successful transition.27 Additionally, early introduction to the concept of transition has been correlated with successful transition.28,29 It remains to be determined at what stage these preparatory practices are occurring and whether the impact on successful transition is favourable. Discussions regarding oral health education and potential treatment options would improve patient and/or carer oral health awareness, which would ultimately help ensure oral health remains on the agenda of multidisciplinary health management of SN patients, especially when studies indicate general medical considerations often take precedence.30–32 Financial considerations, whilst not criteria used by paediatric dentists during the transition process, were considered a barrier and a challenge when looking to facilitate transition. Studies have shown limited government funded financial support directed towards oral health favours the adoption of private insurance schemes.22,33 However, comprehensive cover is often lacking and inadequate in the context of oral health service provision.34 Moreover, there are limited viable alternatives for practitioners to suggest to their patients. In Australia, recent Commonwealth Government budget reforms have rendered the Chronic Disease Dental Scheme, which was set up to assist SN patients, a redundant form of public health policy from 1 December 2012.35 A replacement policy that could provide financial aid for dental treatment of SN adults has not yet been provided. The implication of neglecting the financial burden in facilitating transition may impact negatively on continuity of care, particularly exacerbated in those with special needs.36 Paediatricians are reported to consider the level of independence as the most significant barrier to transition of SN patients to adult oriented care.36 This was also indicated by SN dentists, who considered this on par with financial implications and above the level of maturity and age related barriers. The belief that multiple barriers to transition exist, as seen in this study, further demonstrates the delicate and complex nature of transition in the SN sector. Age was the criteria used by most paediatric dentists as the catalyst for transition of SN patients. The notion of the ageing out of paediatric services is a trend consistently reported in literature regarding criteria for initiating transition of paediatric patients.37 However, particularly in the context of special needs, age represents an arbitrary assessment of the individual and is a poor indicator to initiate transition. The capacity for SN patients to engage with the demands of an adult oriented health care system should take 364
precedence over age based determinants for transition. A developmental approach has been suggested that aims to understand the effects of chronic illness on adolescent development that is independent of age. Delivery of health care in an appropriate developmental context may encourage continuity of care and optimise future management by considering the increased level of independence and maturity required by adult care systems.27 Other studies show transition may be initiated with little regard to chronological age and may preferentially consider criteria such as maturity, independence and access to services.23,38 The perception that multiple criteria should form the standard in deciding to initiate transition was reinforced in the present study, more so from the perspective of SN dentists, whereas age remained the dominant criteria reported by paediatric dentists. CONCLUSIONS The nature of transition as documented by paediatric and SN dentists have been reported in this study. When considering individual SN categories including intellectually or physically disabled, medically compromised, infectious disease and psychological and behavioural conditions, no apparent differences were identified in transition related practices being undertaken in Australia. It can be concluded that key factors exist that should be discussed with SN patients and their parents and/or guardians in order to enhance the prospect of sustained dental care into adulthood. Adequate preparation and understanding of the complex issues surrounding transition of SN patients needs to be apparent to minimize the impact of identified barriers to successful transition. Future studies should be aimed at linking transition practices and outcomes of these practices to inform on the most effective strategies to help maintain optimum oral health standards in the SN population following transition. REFERENCES 1. Royal Australian College of Dental Surgeons. Special Needs Dentistry – MRACDS(SND) and FRACDS(SND) 2011. URL: ‘http://www.racds.org/RACDS/Pathways/FRACDS-SFS/SND/RA CDS_Content/Pathways/SFS/SND.aspx?hkey=76a3e211-588e-4f86-8a5f-003ada1f62c8’. Accessed 15 May 2013. 2. Australian Institute of Health and Welfare. Disability in Australia: trends in prevalence, education, employment and community living. Bulletin no. 61. Cat. no. AUS 103. Canberra: AIHW, 2008. 3. National Advisory Committee on Oral Health. Healthy mouths healthy lives. Australia’s National Oral Health Plan 2004– 2013. Adelaide: Government of South Australia on behalf of the Australian Health Ministers’ Conference, 2004. 4. Desai M, Messer LB, Calache H. A study of the dental treatment needs of children with disabilities in Melbourne. Australia. Aust Dent J 2001;46:41–50. © 2014 Australian Dental Association
Special needs paediatric to adult dental services 5. Edelstein BL, Chinn CH. Update on disparities in oral health and access to dental care for America’s children. Acad Pediatr 2009;9:415–419.
25. AAPD Policy Guidelines. Reference Manual – Overview of Paediatric Dentistry. Am Acad Paediatr Dent 2012–13;34: 2–3.
6. Pope JE, Curzon ME. The dental status of cerebral palsied children. Pediatr Dent 1991;13:156–162.
26. Gallagher JE, Fiske J. Special care dentistry: a professional challenge. Br Dent J 2007;202:619–629.
7. Spencer AJ, Davies M, Slade G, Brennan D. Caries prevalence in Australasia. Int Dent J 1994;44(4 Suppl 1):415–423.
27. Kennedy A, Sloman F, Douglass JA, Sawyer SM. Young people with chronic illness: the approach to transition. Intern Med J 2007;37:555–560.
8. Nelson LP, Getzin A, Graham D, et al. Unmet dental needs and barriers to care for children with significant special health care needs. Pediatr Dent 2011;33:29–36.
28. Alpay H. Transition of the adolescent patient to the adult clinic. Perit Dial Int 2009;29(Suppl 2):S180–182.
9. Mayer ML, Skinner AC, Slifkin RT. Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs. Paediatrics 2004;113:e109–115.
29. de Beaufort C, Jarosz-Chobot P, Frank M, de Bart J, Deja G. Transition from paediatric to adult diabetes care: smooth or slippery? Pediatr Diabetes 2010;11:24–27.
10. Lewis CW. Dental care and children with special health care needs: a population-based perspective. Acad Paediatr 2009;9: 420–426.
30. Migliorati CA, Madrid C. The interface between oral and systemic health: the need for more collaboration. Clin Microbiol Infect 2007;13(Suppl 4):11–16.
11. Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ 2004;68:23–28.
31. Rai K, Supriya S, Hegde AM. Oral health status of children with congenital heart disease and the awareness, attitude and knowledge of their parents. J Clin Pediatr Dent 2009;33:315– 318.
12. Crall JJ. Improving oral health for individuals with special health care needs. Pediatr Dent 2007;29:98–104. 13. Nowak AJ. Patients with special health care needs in paediatric dental practices. Pediatr Dent 2002;24:227–228.
32. Yoon MN, Steele CM. Health care professionals’ perspectives on oral care for long-term care residents: nursing staff, speechlanguage pathologists and dental hygienists. Gerodontology 2012;29:e525–535.
14. Simon TD, Lamb S, Murphy NA, Hom B, Walker ML, Clark EB. Who will care for me next? Transitioning to adulthood with hydrocephalus. Pediatrics 2009;124:1431–1437.
33. Callahan ST, Cooper WO. Continuity of health insurance coverage among young adults with disabilities. Pediatrics 2007;119:1175–1180.
15. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating the transition of patients with special health care needs from paediatric to adult oral health care. J Am Dent Assoc 2010;141:1351–1356.
34. Harford J, Spencer AJ. Government subsidies for dental care in Australia. Aust N Z J Public Health 2004;28:363–368.
16. Reiss J, Gibson R. Health care transition: destinations unknown. Pediatrics 2002;110:1307–1314. 17. Davis MJ. Issues in access to oral health care for special care patients. Dent Clin North Am 2009;53:169–181. 18. Dental Board of Australia. URL: ‘http://www.dentalboard.gov.au/ Search.aspx?q=special needs transition’. Accessed 15 May 2013. 19. Australian Dental Association. URL: ‘http://www.ada.org.au/ search.aspx?search=special needs transition’. Accessed 15 May 2013. 20. Oredugba FA, Perlman SP. Oral health condition and treatment needs of Special Olympics athletes in Nigeria. Spec Care Dentist 2010;30:211–217. 21. Lam PY, Fitzgerald BB, Sawyer SM. Young adults in children’s hospitals: why are they there? Med J Aust 2005;182:381–384. 22. Lotstein DS, Inkelas M, Hays RD, Halfon N, Brook R. Access to care for youth with special health care needs in the transition to adulthood. J Adolesc Health 8;43:23–29. 23. Reiss JG, Gibson RW, Walker LR. Health care transition: youth, family, and provider perspectives. Pediatrics 2005; 115:112–120. 24. Dental Council of New Zealand. Notice of Scopes of Practice and Prescribed Qualifications. URL: ‘http://www.dcnz.org.nz/ Documents/Scopes/ScopesOfPractice_Dentists.pdf’. Accessed 15 May 2013.
© 2014 Australian Dental Association
35. Australian Government. Department of Health and Ageing. Dental Health Chronic Disease Dental Scheme. URL: ‘http:// www.health.gov.au/internet/main/publishing.nsf/Content/dental+ care+services’. Accessed 15 May 2013. 36. Burdo-Hartman WA, Patel DR. Medical home and transition planning for children and youth with special health care needs. Pediatr Clin North Am 2008;55:1287–1297. 37. Fishman E. Aging out of coverage: young adults with special health needs. Health Aff (Millwood) 2001;20:254–266. 38. McManus M, Fox H, O’Connor K, Chapman T, MacKinnon J. Paediatric perspectives and practices on transitioning adolescents with special health care needs to adult health care. Available at: ‘http://www.thenationalalliance.org/pdfs/ FS6.%20Pediatric%20Perspectives%20and%20Practices%20on %20Transitioning.pdf’.
Address for correspondence: Associate Professor Gelsomina Borromeo Melbourne Dental School The University of Melbourne 720 Swanston Street Melbourne VIC 3010 Email: [email protected]
365
