to completely finance the oral health needs of these patients (Killmurray, 2019). The problem of inadequate or absent dental insurance is especially acute in adults with a disability because most are poor and often unemployed or underemployed with limited resources to purchase out-of-pocket care (Moore, 2017). Even if private dental insurance is available, there is limited third- party support for the delivery of complex services. The predominant funding mechanism for oral health care for most people with special healthcare needs is Medicaid. Benefits for dental care differ from state to state, but dentist participation in the Medicaid program is very low (Editors, 2019; AAPD, 2021; ADA News, 2018). Only a small number of dentists enrolled in the Medicaid program see more than 100 Medicaid-eligible patients inclusive of children in a year (Vujicic, et al., 2021). Reasons cited include administrative (paperwork) burden, appointment no-shows, broken appointments by patients enrolled in Medicaid and a lack of patient awareness of the importance of oral health as a component of systemic health (Brickhouse, et al., 2021). Participation among dental specialists in the Medicaid Program range from 73% among pediatric Lack of integrated and tiered system for delivery of care In many instances, people with special needs for optimal outcomes require coordination among providers of oral health care, general health care, and social services. The artificial division between the oral healthcare system and the general health and social services systems limits cooperation between them (Moore, 2017). Poor integration between existing medical and dental systems creates challenges to maintaining and improving oral health for people with special healthcare needs. The greater the complexity of the health issues of a special needs patient the greater the need for an interdisciplinary approach between the medical and dental professions (SCDA, 2017). Provision of care to patients with special needs often requires a tiered delivery system. This system tailors both the treatment and setting to the patient’s specific dental needs (Monteserin-Matesanz, et al., 2015).
dentists to 25% among periodontists (Davis, 2020). Inadequate compensation through Medicaid is also a major impediment. In many states, Medicaid reimbursement fails to reflect the complex issues involved in caring for patients with special needs, including the need for more time to complete procedures on children or the elderly and increased consultation with health and social service professionals (Editors, 2019). Another roadblock to good oral health care is the lack of reimbursement for some procedures or services (Moore, 2017). For example, funding is rarely available for coordination or case management between physicians and dentists. The age limit of Medicaid is another problem. Although all low-income U.S. children up to the age of 6 have comprehensive dental coverage under Medicaid and its Early and Periodic Screening, Diagnosis, and Treatment program, thousands of children and adults with disabilities “age out” of Medicaid dental services each year. Overall, there are inadequate incentives for dental professionals to treat patients with special healthcare needs who may take more time to treat and may produce less income. For example, a patient with Parkinson’s disease might be served best by an appointment 1 hour after taking his or her Parkinson’s medication. This appointment time and duration would coincide with the maximal effectiveness of the medication regimen. The delivery setting is also a key component to successful outcomes. The patient with autism, for example, might require a more private setting with a consistent dentist and auxiliary team. A larger clinic setting that is more chaotic and loud might not be the appropriate setting for this patient. In sum, the increase in the number of patients with special healthcare needs, the current and anticipated shortages in the oral healthcare workforce, inadequate training of oral health professionals, and a reimbursement system that insufficiently rewards services needed by patients with special needs all contribute to the failure of the current system.
MANAGEMENT AND TREATMENT GUIDELINES FOR DENTAL PATIENTS WITH SPECIAL HEALTHCARE NEEDS
In recent years, a number of articles in the literature have addressed the issue of oral health in patients with special healthcare needs and provided recommendations to improve the level of care (SCDA, 2017; Milano, 2017; Moore 2017; Alumran 2018). In addition, clinicians increasingly look toward evidence-based treatment options for guidance in the context of oral health. For many practitioners, these recommendations help in making informed choices about best practices to achieve better outcomes. Accordingly, national governing bodies have promulgated guidelines on the management of dental patients with special healthcare needs to optimize oral health and have revised these guidelines in 2021 (AAPD, 2021).
While the significant oral health and oral healthcare issues in adults with special needs generally parallel those of children, many dentists lack the training which is needed to provide dental care to children and adults with special needs. Many children with special needs are treated by pediatric dentists but the transition to adulthood can leave these patients searching for a dentist who is capable of treating an adult with special needs. In 2021 the AAPD Council on Clinical Affairs issued revised guidelines for the purpose of educating providers, parents, and ancillary organizations about the management of individuals with special healthcare needs (AAPD, 2021). This section summarizes some of the recommendations in these guidelines.
SCHEDULING APPOINTMENTS
While scheduling an appointment, the office staff should obtain information about the patient’s special healthcare needs. This information will assist the staff in providing an appropriate number of auxiliary staff, appropriate setting, and adequate appointment duration (AAPD, 2021). In consultation with the patient’s primary care physician when appropriate, the dentist and team can prepare for a first appointment by understanding the unique needs of the patient. In a morning huddle, the dental team can discuss the most efficient and caring way to deliver care. Following the appointment, an additional staff meeting can review what was learned, assess successes and failures,
and determine the best way to schedule and manage future appointments. It is also important to keep in mind that the documentation of medical and psychosocial information must comply with the Health Insurance Portability and Accountability Act (HIPAA) and ADA regulations applicable to dental practices which originally went to effect in 1996 and had its last major updates in 2013. It is mandatory that all dental clinicians stay abreast of any update under (HIPAA) policies and must communicate any changes to all staff members who deal with confidential patient information. (HIPAA Journal, 2019).
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