People with special healthcare needs suffer disproportionately from periodontal disease and edentulism, have more untreated caries, have poorer oral hygiene, and receive less care than the general population. (Milano, 2017; Alumran et al., 2018). In
general, the literature, although limited, documents poorer oral hygiene, more periodontal disease, and greater treatment needs among persons with disabilities than persons without disabilities.
INADEQUACIES OF THE CURRENT ORAL HEALTHCARE SYSTEM
Despite their greater need for oral care, patients with special healthcare needs receive inadequate oral care. Children without special health care needs were more likely to receive preventive dental than children with special health care needs (Obeidat, et al., 2022). There is an increased prevalence of poor oral hygiene with the subsequent development of gingival and periodontal problems and an increased occurrence of carious lesions among children with special health care needs compared to that of the general population (Dharmani, 2018). It is estimated that 18.5% percent or approximately 13.6 million children in the United States have special healthcare needs and have challenges in
obtaining their required dental care (U.S. Department of HRSA, 2020). Various factors cause limited access to and underutilization of oral health services by patients with special needs. Access challenges occur because patients are unable to obtain basic oral healthcare services in environments where more advanced care is valued. Workforce shortages, poor training of oral healthcare professionals, and a reimbursement system with emphasis on aesthetic rehabilitation result in suboptimal oral healthcare delivery for underserved populations in need of basic care. Despite statutory requirements to treat patients with special healthcare needs, these patients often find it difficult to access oral care in the community setting. In the community, adults with disabilities may travel a considerable distance to find a dental professional willing and able to provide services. Lack of physical access to dentists capable of treating them is another barrier to care, especially for persons living in rural areas. Deinstitutionalization has aggravated the challenges to patients with special needs in accessing oral care, especially as they move from childhood to adulthood. Even when treatment is available, it is often provided in a less controlled setting in the community. The number of professionally active dentists and the composition of the dental workforce are other factors in limiting the availability of dental providers to serve special needs populations. As of 2020 there were 201,117 active general dentists in the United States which equates to 61.0 dentists per 100,000 population (Munson & Vujicic, 2021).This is compared with the approximately 61 million persons with disabilities (CDC, 2019). The lower population growth and an increased supply in the number of dentists will change the dentist ratio to 67.0 per 100,000 population by 2040 (Munson & Vujicic, 2021). There is an increasing percentage of dentists who are female and who are more likely to work part-time or work fewer or different hours than their male colleagues to accommodate family needs (Needham, 2017). So, although there may be more practicing dentists, their availability may still be limited, making locating a dentist willing or able to treat special needs patients even more challenging. on experience in caring for patients with disabilities, but those who receive training during dental school or in the early years of practice may be more likely to treat the patients with special needs (Moore, 2017). The experience at the postdoctoral level is even more limited, with only a few programs offering the training necessary to treat patients with special needs. Yet studies have reported that positive correlations exist between hands-on training during school and the future intent of dentists to treat special needs patients. (NCD, 2017). Although more dentistry programs are providing special needs experiential training, there are still insufficient numbers of dentists or hygienists receiving advanced training to treat the growing number of adults with disabilities.
Difficulty finding dental care for patients with special needs In previous generations, people with physical and mental disabilities were often placed in institutions, some of which had preventive dentistry programs. The discovery of the deplorable conditions of many state-run institutions in the 1970’s led to a trend of de- institutionalization across the United States which left many of those who were intellectually and/or developmentally disabled without access to the government sponsored oral healthcare programs (NCD, 2017). According to the Americans with Disabilities Act (ADA), the dental office is a place of public accommodation. Consequently, failure to accommodate patients with special needs could be considered discriminatory behavior and violate federal or state law.
Limited availability of providers Other systemic barriers are a deficiency of dental providers trained to serve special needs populations and dental offices that are not physically equipped to accommodate them (Alumran, et al., 2017). It is estimated that only 10% of dentists in the United States have the training that is required to meet the diverse needs of patients with special health care needs (Killmurray, 2019). Based upon the recommendation of the National Council on Disability (NCD), all dental schools in the United States must revamp their curricula to include clinical programs which feature treatment of patients with intellectual and developmental disabilities (National Council on Disability, 2019). Without the adequate didactic and clinical training at an undergraduate level and a scarcity of lecture and “hands- on”/clinical courses available which teach clinical modalities of treatment of special needs patients after graduation it is no surprise that many general dentists feel that they are not prepared to meet the diverse oral health needs of these patients. Inadequate training of dental professionals Inadequate training of oral health professionals also contributes to the failure of the current system for patients with special healthcare needs. Until recently, accreditation standards had no requirements for dental and dental hygiene education programs to give students experience in treating people with special healthcare needs. Many dental professionals report that they are poorly prepared or totally unprepared to treat disabled patients (NCD, 2017; Alumran, et al., 2018) The limited training of predoctoral dental students and prebaccalaureate hygiene students in providing oral care to patients with special needs is mainly focused on persons with mild to moderate disabilities. Predoctoral dental students typically receive only didactic training with no hands- Financial disincentives for optimizing oral care Among persons with special healthcare needs, financial impediments often restrict access to care. These include a lack of personal financial resources, unavailability of private dental
insurance, and inadequate public dental programs (Moore, 2017; AAPD, 2021). For families with children with special needs, insurance plays an important role but is inadequate
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