Combating the Oral Epidemic in Children with Special Needs-By Munir Gomaa

My recent post discussed the preventable nature of the very real oral health epidemic targeting special needs patients. But let’s be honest, who amongst us in our hectic lives has time to address the oral health of the mentally challenged? Fair enough, layman, you’re off the hook. Go live your lives, take care of your own teeth, and be helpful to the underserved in other ways. But, dentists? More importantly, dental schools? Your voices and your actions can make a real difference for the 54.4 million special-needs patients in the US. I won’t speak for every dentist or every dental school in the nation; I can only reference the patterns I’ve noticed from research over the last forty-some years.

In 1979, a study involving over 500 dental students showed that students are willing to treat handicapped patients if they feel capable of doing so. Moreso, as instruction in disability management increased, students had significantly increased levels of perceived confidence in treating these patients. Ok, no brainer—give students more experience with treating special-needs patients, and they’re more likely to do so throughout their career. In 1993, in a survey of US and Canadian dental schools, the average amount of lecture hours about the management of disabled patients was less than 13 hours and the average clinical instruction was 17.5 hours. Considering how time-consuming appointments are at dental schools (in my program, for instance, 3 hours are allotted per appointment), this isn’t very impressive. 32 schools included less than 10 hours of instruction on this topic in their curriculum. 6 years later, a follow-up survey showed that these numbers worsened: over half of dental schools reported less than 5 hours of lecture-based instruction and over 70% of schools reported that between 0-5% of each student’s clinical instruction was dedicated to treatment of special needs patients. In 2004, over half of fourth-year dental students from 5 dental schools reported having no experience in treating the mentally challenged population.

Although I won’t mention every study out there, several studies replicate these findings and additionally show that students attending most US dental schools feel that they aren’t gaining enough clinical experience with special-needs patients to feel comfortable treating them in practice.

It’s apparent that most dental students lack the experience and confidence to treat special-needs patients, but what about general dentists? A study consisting of over 200 general dentists from the Michigan Dental Association showed that most general dentists felt that their undergraduate education had not prepared them well to treat patients with special needs. This study also showed that the more these dentists believed their undergraduate education prepared them well to work with this population, the more likely they were to treat them in practice. The conclusion here, of course, is that most general dentists won’t treat these patients because they lack confidence in doing so.

In another study, dentists and dental staff agreed in a survey that mentally-ill patients have significantly more anxiety related to dental treatment than the general population, and that this anxiety acts as a barrier to them receiving, and for dentists providing, treatment. However, this same study showed that there was no significant difference in the frequency of sedation in these patients versus other patients. Sedation is a common technique used by dentists to treat patients who are too fearful, anxious, or non-compliant to receive dental care. It is often the only means by which they can receive any dental treatment throughout their lives. If mentally challenged patients aren’t being sedated more frequently than the general population, most are likely not receiving the dental treatment they need altogether.

The root of the problem likely lies within the Commission of Dental Accreditations’ “Accreditation Standards for Dental Education Programs.” These are a set of standards that every dental school in the US must incorporate into their curriculum. Pertaining to special-needs patients, section 2-24 states “Graduates must be competent in assessing the treatment needs of patients with special needs.” Basically, this ensures that graduates simply know how to diagnose, but not necessarily treat, this population. The section continues, “An appropriate patient pool should be available to provide experiences that may include patients whose medical, physical, psychological, or social situations make it necessary to consider a wide range of assessment and care options.” The ambiguity in the phrase ‘appropriate patient pool’ allows dental schools to decide just how many special-needs patients they feel are enough to mandate their students to see.

Perhaps the most liberating part of the section is the last sentence, “Clinical instruction and experience with the patients with special needs should include instruction in proper communication techniques and assessing the treatment needs compatible with the special need.” Nowhere in this paragraph does the Commission mandate students to go beyond learning to communicate with and diagnose special-needs patients.

I write all this to raise awareness on this issue, which has always been a problem and will continue to be one unless the Commission of Dental Accreditations raises the bar for the way dental schools must instruct its’ students to treat special-needs patients. In my opinion, section 2-24 should be revised to obligate students to gain the clinical competency necessary to diagnose and treat special-needs patients, just as any other patients. It’s quite the irony that a population whose treatment needs have always been greater than the general population’s aren’t given half us much attention. It’s my sincere hope that this change is soon realized, and in the meantime, that dental schools take their own initiatives in revising their curricula to instill the confidence their students need to treat special-needs patients upon graduating.

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