At #hcldr we spend all of our time talking and listening to everyone we meet in healthcare and other fields. We see the opportunities to bring people together, listening to many points of view. After all, no one has all the answers. Sometimes, in the roar of all the talking, meeting, and sharing, we […]
Someone finally comments on this. Month after month we hear about more hospitals being bombed, more doctors killed. Very sad.
An underground network of medical workers and trauma surgeons in Syria, led by David Nott, aims to spread medical knowledge as the Syrian government strives to eradicate it.
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.
We owe it to these two to better our world, to fight against our own biases, and to stand up to racism. If we want to serve others, we need to sincerely respect and value the populations and lives we serve. RIP.
“But we owe to Alton and Philando, we owe to ourselves and our children, what we have ever been owed: some semblance of life, the inordinate idea that, as long as we draw breath, that life can still improve.” Stacia L. Brown reflects on the killings of Alton Sterling and Philando Castile.
It’s important to make attempts to understand and see the perspectives of your patients. Read and learn about others–that will broaden your humanity and broaden your ability to best serve your patients.
“How do you explain to someone what it’s like to not have something that you don’t even know exists? It’s like trying to describe silence to someone who has always lived their life beneath a roaring waterfall. They won’t hear the water. They’ll take it for granted. They’ll say, ‘This is silence.’”
On providing care to others even when it is difficult…
As health professionals, we often come across patients who are more difficult to treat than others, be it because of their racist comments or a difficult history you’ve shared with that patient. This is one example of a person who selflessly cared for her mother in her greatest time of need, despite unimaginable difficulties.
“Despite my resentments over the secrets I had to keep and the care I was obligated to give her growing up — despite anything else at all — she is still my mother.” Jane Demuth writes about her complicated relationship with her mother.
Another example of a minorities whose identities restrict them from appropriate access to healthcare. Health professionals need to be mindful of these dichotomies and create a space for individuals who are often robbed of proper access to healthcare. People of color with autism….
Steve Silberman, the author of NeuroTribes: The Legacy of Autism and the Future of Neurodiversity, explores the challenges faced by autistic people of color in gaining access to proper health care.
Considerations when serving the elderly. We have too much to learn:
“I looked down at my now sleeping Mom. She was laying there naked faced, no lipstick, her thinning hair completely flattened and messy, and wrapped in a flimsy, faded hospital gown. And, I thought she had never looked more beautiful in her entire life.”
By: Munir Gomaa
A few weeks ago, several of my dental school classmates and I were privileged with the opportunity to volunteer at a local resource center that provides community-based, educational services to students with severe developmental disabilities. The majority of these students, ranging from 3 to 21 years of age, have profound mental retardation that significantly impairs their ability to perform simple daily tasks, such as eating and drinking, communicating, and, of course, brushing and flossing. My colleagues and I spent the morning performing oral-health screenings on these children, making referrals to our school’s clinic for emergent care when necessary. Our time with each patient was brief. Screenings were performed in a small classroom–many were in wheelchairs as we performed one-minute examinations whenever possible, often only catching a glimpse or two of the oral cavity.
To nobody’s surprise, the oral-health of most of these students was amongst the poorest we’ve seen in children since we began treating patients a year ago. A plethora of dental problems were noted, ranging from neglected oral hygiene and severe tooth wear to rampant tooth decay and non-restorable teeth. Many of these children will require dentures as young adults, suffering from the reduced chewing efficiency by at least 50% that is typically associated with these prostheses. That’s not to mention the enormous difficulty even mentally healthy patients undergo for the first few months of wearing dentures, which include relearning to eat and speak, just as one with a prosthetic leg must relearn to walk. Envisioning the countless oral-health problems these children must overcome in addition to the physical and mental impairments they already experience daily is heartbreaking.
And yet, dental diseases such as caries and periodontal disease are among the most preventable chronic diseases one can be inflicted with through proper oral hygiene, a healthy diet, and regular visits to the dentist. If we had the similarly cheap and effective knowledge and resources for treating diabetes or cancer, there’s almost no doubt that the incidence of these diseases would decline substantially. This isn’t to imply that dental diseases are comparable in magnitude to these life-threatening diseases, however most people are simply unaware of the systemic impact, both physiological and psychological, that one’s dental health has been shown to have. Most people don’t know that periodontal disease has been shown to have significant associations with cardiovascular disease (including stroke and coronary heart disease), diabetes mellitus, bacterial pneumonia, low birth-weight babies and pre-term births. They haven’t a clue that the cavities in their mouths have been significantly linked with hepatitis, hypertension, asthma, stroke, liver disease and diabetes. If they did, dental caries surely would not remain the most prevalent chronic disease in both adults and children. Periodontal disease wouldn’t be affecting nearly 50% of all adults and 70% of adults 65 and up. 1 in 4 adults over the age of 60 wouldn’t have lost all of their natural teeth.
Despite these alarming statistics, recent times has shown a large decline in dental disease, due to factors such as water fluoridation and oral health promotion. However, research has reliably shown that those who suffer from severe mental illness have not shared in these improvements. This population has suffered and will always continue to suffer from a greatly increased risk of oral disease due to a number of factors, such as xerostomia (dry-mouth) commonly associated with psychotropic medications, tobacco and drug usage (over a third of those with any behavioral disorder in the US smoke cigarettes), significant fear and anxiety associated with the dentist, lack of oral-hygiene knowledge and habits, poor living conditions that negatively impact their diet, etc. The list really does go on and on, and every additional factor places this particular population at a much larger risk than the general population. Mentally-challenged or not, the more oral-health problems one has, the more fear and anxiety of the dentist typically overpowers them, and the less willing they are to make a trip to the dentist, let alone allow a dentist to treat them. And yet, this topic remains largely unspoken as the vicious cycle continues.
What initiatives are being taking to target the oral epidemic that exists in special needs patients? Why isn’t it working? And most importantly, what can be done to make a real difference for this at-risk population? Research over the past few decades begins to shed light on these questions, and the answers can be rather frustrating. I’ll share all this along with my ideas shortly.