Is Mandating that Dental Students be Prepared to Care for Individuals with Special Needs the Answer?
H. Barry Waldman, DDS, MPH, PhD; Steven P. Perlman, DDS, MScD
In 2004, the Commission on Dental Accreditation (CODA) adopted new standards for dental and dental hygiene education programs to ensure didactic and clinical opportunities to better prepare dental professionals for the care of persons with developmental disabilities, complex medical problems, significant physical limitations, and a vast array of other conditions which are considered under the general term of “individuals with special needs.” Implementation of these revised standards was required by January 2006.1
CODA’s action would seem quite appropriate and timely, given the findings from the 2000 US Census that almost 50 million civilian, non-institutionalized individuals 5 years of age and older had at least one disability:
- almost 1 out of 5 Americans (19%); specifically 17% of Asian Americans, 18% of non-Hispanic whites, and almost 1 out of 4 (24%) black and Native Americans.
- 24.4 million males (20% of all males) and 25.3 million females (19% of all females).
- 2.6 million children between 5 and 15 years; 33.1 million children and adults between 16 and 64 years; and 13.9 million adults 65 years and over.2
While mandating that dental schools prepare new practitioners for the care of individuals with special needs is an appropriate step, the implementation is far more complex.
Faculty and Funding
The cover article of the first edition of Inside Dentistry emphasized the ongoing shortage of dental educators.3 Now add to this the fact the limited numbers of trained and prepared practitioners available to provide the didactic and clinical programmatic support for the care of patients with special needs. Faculty positions continue to go unfilled as practitioners are unwilling to leave lucrative practices for teaching appointments with limited compensation, which, in turn, results in the precarious financial state of dental schools. In addition, recent graduates are reluctant to pursue a full-time career in academia because of their outstanding debt load and, once again, inadequate remuneration.4
Economics and the Special Case of Dentistry
The frequent reporting that there are between 40 and 50 million individuals in the United States who have no health insurance, together with the associated health and economic consequences fills government reports, publications of the various health professions, the printed media, and the evening news.5 The fact that approximately 15% of the population has no health insurance is in itself grave, and almost beyond comprehension considering the extent of private insurance arrangements and government programs. But even more significant is the reality that, despite some recent decreases in the proportion of the population without health insurance, the use of a single national summary figure masks and understates the true magnitude and variability of the numbers and proportion of children and adults who lack total or particular components of necessary coverage. Consider the following:
- Families with children with special healthcare needs are best protected against inpatient hospital costs and most exposed to dental care expenses.6 Results from the National Survey of Children with Special Health Care Needs (CSHCN), conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics, emphasize further the contributing consequences of a lack of dental insurance coverage. More than three quarters (78%) of the children with CSHCN required dental care in the past year (second only to prescription medications in the frequency of need). More than 750,000 of these children did not receive all of the dental care they needed.7
- 44 million Americans lack medical insurance, but about 108 million lack dental insurance.8
- In 2003, approximately 44% of dental service costs were paid out-of-pocket; a far greater proportion than all other major healthcare services. Specifically, 3% of hospital care costs, 10% of physician service costs, 25% of nursing home and home healthcare costs, and 35% of prescription drug costs were paid out-of-pocket. The reality is government spending for dental services has been particularly limited. Since 1980 (with projections through 2011), the government’s proportion of spending for overall personal healthcare services (including federal, state, and local agencies) ranged from 39% to 44%. But government spending for dental care services ranged from 2.9% in 1990 to 5.6% in 2001, with projections that it will reach 7.3% in 2011.9
In particular, Medicaid dentistry
Compared with other children, in 2000 children with special healthcare needs had three times higher healthcare expenditures. Yet, the fact is there is a progressive increase, with age, in the proportion of children with special healthcare needs who have no insurance. In addition, more than 1 in 5 children had public health insurance coverage, principally Medicaid coverage—the primary source of insurance for many individuals with disabilities.6 But after years of enduring Medicaid shortcomings, most dentists are unwilling to participate in the program.10 And, because of the severe limitation of adult Medicaid dentistry in many states, children (including those with special healthcare needs) once eligible for dental care services under the Early and Periodic Screening, Diagnostic and Treatment Medicaid program are aging out of dental care.11
Mandating educational change
Cataloguing the obstacles that challenge individuals with intellectual, developmental, and other disabilities—and who increasingly reside in community and family residencies—has been covered by numerous journal articles and individual patient-case histories. But these impasses still need to be resolved.
A group of advocates is now approaching the Health Resources and Services Administration (HRSA) in an effort to have individuals with intellectual and developmental disabilities included in HRSA’s definition of medically underserved populations (currently the definition is based on the ratio of primary medical care physicians per 1,000 population, infant mortality rates, percentage of the population with incomes below the poverty level, and percentage of the population age 65 years and over).12 For example, under such a program to extend the definition of medically underserved populations, there would be an incentive of loan forgiveness (and grants) for dental (and medical) practitioners to provide services to individuals with intellectual and developmental disabilities. (Note: in 2002, student education debts for almost 3 out of 5 dental school graduates were in excess of $100,000.13)
The adoption of new standards for the education of dental and dental hygiene practitioners to prepare them to care for individuals with special needs is a critical step. So too would be the successful expansion of the definition of medically underserved populations. But none of these efforts would be successful without the active participation of private dentists. It should be noted that the young and the not so young with special healthcare needs often are members of families currently receiving care in many community practices. In short, a next essential step is up to you.
1. American Dental Association Commission on Dental Accreditation. Accreditation standards for dental education. Chicago: American Dental Association Commission on Dental Accreditation. 2004. Standard 2-16, Clinical Sciences.
2. US Census Bureau. Americans with Disabilities: 2002. Available at: http://www.census.gov/hhes/www/disability/sipp/disable02.html. Accessed February 8, 2007.
3. DiMatteo AM. At the head of the class: your profession, your role, your future. Inside Dentistry. 2005;1(1):40-51.
4. Waldman HB, Fenton SJ, Perlman SP, et al. Preparing dental graduates to provide care to individuals with special needs. J Dent Educ. 2005;69:249-254.
5. DeNevas-Walt C, Proctor BD, Mills RJ. US Census Bureau, Current Population Reports. Income, poverty, and health insurance coverage in the United States: 2003. Washington, DC: US Government Printing Office, 2004; pp 60-226. Available at: http://www.census.gov/prod/2004pubs/p60-226.pdf. Accessed February 8, 2007.
6. Newacheck PW, Kim SE. A national profile of health care utilization and expenditures for children with special health care needs. Arch Pediatr Adolesc Med. 2005;159(1): 10-17.
7. Blumberg SJ, Osborn L, Luke JV, et al. Estimating the prevalence of uninsured children: an evaluation of data from the National Survey of Children with Special Heath Care Needs, 2001 Data evaluation and methods research. Hyattsville, Md: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Vital Health Stat 2. 2004;136: 1-38.
8. National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon General. Bethesda, Md: National Institutes of Health; 2000. Accessed February 8, 2007.
9. Heffler S, Smith S, Won G, et al. Health spending projections for 2002-2011: latest outlook. Health Affairs. 2002;21(2):207-218.
10. Lewis C, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: implications for the medical home. Pediatrics. 2005;116(3):426-431.
11. Waldman HB, Perlman, SP. Children with disabilities are aging out of dental care. ASDC J Dent Child. 1997;64: 385-390.
12. Bureau of Health Professionals. Guidelines for Medically Underserved Area and Population Designation. 2005. Rockville, Md: US Department of Health and Human Services, Health Resources and Services Administration. Accessed February 8, 2007.
13. Weaver RG, Haden NK, Valachovic RW, et al. Annual ADEA survey of dental school seniors: 2002 graduating class. J Dent Educ. 2002;66(12):1388-1404.
About the Authors
H. Barry Waldman, DDS, MPH, PhD
Distinguished Teaching Professor
Department of General Dentistry
School of Dental Medicine
Stony Brook University
Stony Brook, New York
Steven P. Perlman, DDS, MScD
Associate Clinical Professor of Pediatric Dentistry
The Boston University Goldman School of Dental Medicine
Global Clinical Director
Special Olympics, Special Smiles
Private Practice in Pediatric Dentistry