January 1, 2013
by Edward L. Rick, DDS, MS
The American Academy of Pediatric Dentistry (AAPD) defines Special Health Care Needs (SHCN) to include any physical, developmental, mental, sensory, behavioral, cognitive or emotional impairment or limiting condition that requires medical management, health care intervention and/or use of specialized services or program. The condition may be congenital, developmental or acquired through disease, trauma or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for individuals with SHCN requires specialized knowledge acquired by additional training, as well as increased awareness and attention, adaptation and accommodative measures beyond what are considered routine.
AAPD recognizes that providing both primary and comprehensive preventive and therapeutic oral health care to individuals with SHCN is an integral part of the specialty of pediatric dentistry. The AAPD values the unique qualities of each person and the need to ensure maximal health attainment for all, regardless of developmental disability or other special health care needs. Finding a dental home to address their special circumstances while providing all aspects of oral care in a comprehensive, continuously accessible, coordinated and family-centered way may be a challenge. Additionally, AAPD recognizes the importance of transitioning patients with SHCN to an adult home as they reach the age of majority. Access to care and transitioning issues are of great concern to AAPD.
According to the U.S. Census Bureau, the proportion of children in the U.S. with SHCN is estimated to be approximately 12.5 million. In addition, each year in the U.S., 750,000 adolescents with SHCN cross into adulthood. Oral health is an inseparable part of general health and well-being and individuals with SHCN may be at an increased risk for oral disease throughout their lifetime. Dentistry has been found to be the most common category of unmet health care for children with SHCN.
The relatively small number and distribution of pediatric dentists, however, means that the broader involvement by general dentists is necessary to address access to care issues and to transition patients with SHCN. Only 10% of surveyed general dentists report that they treat patients with SHCN often or very often, while 70% report that they rarely or never treat patients with SHCN. Addressing the manpower issue is of the upmost importance.
Several reports articulated that prior experience with a disability population led students to be more likely to feel comfortable providing their care. It has been demonstrated that students were 10 times more likely to see intellectually challenged patients in their offices if they had had previous experience.
A survey of senior dental students in the past noted that the provision of oral health care to patients with SHCN is among the top four topics in which they were least prepared upon graduation. A recent survey of general dentists found that only 10% routinely treat children with SHCN and only a quarter of those reported receiving any hands-on experience with patients with SHCN in dental school.
An effort to improve the number of graduating dental students’ self-perceived competency in treating patients with SHCN is underway. It should be noted that the Commission on Dental Accreditation of the American Dental Association introduced an accreditation standard requiring dental schools to ensure that curricular efforts are focused on educating their students on how to assess treatment needs of patients with SHCN.
Oral health care for adults with SHCN is often difficult to access because of a lack of trained providers, and because of this, training and instruction for healthcare providers may be necessary through post-doctoral educational courses. Programs such as general practice residencies and advanced education in general dentistry provide opportunities for additional medical, behavioral guidance, and restorative training needed to treat patients with SHCN.
Facilitating health care transition for patients with SHCN has received national attention from several organizations recognizing the need to support the process. To improve health care transition for adolescents and young adults with chronic conditions, a policy statement was established by a number of medical organizations. The policy statement articulates six “critical steps” to ensuring the successful transition to adult-oriented care. Although these “steps” represent a medical prospective for successful transition between pediatric and adult care, they may be applied to the dental situation. These steps provide a framework to organize and prepare the dentist, patient and patient’s family for the transition process.
A discussion about transition can begin early, although the transfer of care may not take place for many years. There is agreement in the literature that specific transition planning should begin between the ages of 14 and 16 years of age. In cases where this is not possible or desired, the dental home can remain with the pediatric dentist and referrals for specialized dental care should be recommended when needed.
A coordinated transition from a pediatric-centered to an adult-centered dental home is critical for extending the level of oral health and health trajectory established during childhood. AAPD supports:
1. Expanding the medical and dental home across the lifespan of a patient, especially to enable successful transition of the adolescent with SHCN;
2. Partnering with other organizations to prepare general dentists to accommodate and provide primary health care for those patients in the usual dental setting;
3. Developing special programs or alternative care delivery arrangements (e.g. mobile dental programs, nursing home, and group home facilities) to complement the care provided through private practice to address issues for patients with SHCN.
4. Utilizing the six “critical steps” to maximize seamless health care transition for adolescent dental patient with SHCN.
AAPD encourages dentists to be familiar with community-based resources for patients with SHCN and encourage such assistance when appropriate. While local hospitals, public health facilities, rehabilitation services or groups that advocate for those with SHCN can be valuable contacts to help the dentist/patient address language and cultural barriers, other community-based resources may offer support with financial or transportation considerations that prevent access to care.
A patient may suffer progression of his/her oral disease if treatment is not provided because of age, behavior, inability to cooperate, disability or medical status. Postponement or denial of care can result in unnecessary pain, discomfort, increased treatment needs and costs, unfavorable treatment experiences and diminished oral health outcomes. Dentists have an obligation to act in an ethical manner in the care of patients. Once the patient’s needs are beyond the skills of the practitioner, the dentist should make necessary referrals in order to ensure the overall health of the patient.
A vision of the AAPD is optimal health and care for persons with SHCN and the AAPD values improvement in access to oral health care that reduces or eliminates financial, logistic and cultural barriers to care for our patients with SHCN.OH
Edward L. Rick, DDS, MS. Private Practice, Pediatric Dentistry, Peoria and Sterling, Illinois. Adjunct Faculty, Clinical Professor, Department of Pediatric Dentistry, College of Dentistry, University of Iowa, Iowa City. Faculty, General Practice Residency, OSF Saint Francis Medical Center. District IV Member, Council on Clinical Affairs. Chair, Committee on Special Health Care Needs. Member, Pierre Fauchard Academy. Member, American Academy of Developmental Medicine and Dentistry. Manual M. Album Award, presented annually to the individual or organization that has ma
de the greatest contribution to the oral health of children with special needs. Outstanding Physician and House Staff Angel Award, OSF Saint Francis Medical Center and Children’s Hospital of Illinois. Peoria District Dental Society “Thank You Award”, in recognition of Significant service contribution to children and the field of Dentistry, Give Kids a Smile Day, American Academy of Pediatric Dentistry Certificate of Appreciation, AAPD Head Start Dental Home Initiative, Past President, Illinois Society of Pediatric Dentists, Past Medical Staff President, CGH Medical Center. Sterling, Illinois. Past Chairman, Credentials Committee, CGH Medical Center, Sterling, Illinois. Past Chairman, Whiteside Co. Illinois Comprehensive Healthcare Planning Committee. Past President, Sterling-Rock Falls United Way.
Oral Health welcomes this original article.
1. American Academy of Pediatric Dentistry. Definition of dental home. Pediatr Dent 2012; 34 (special issue):16.
2. American Academy of Pediatric Dentistry. Guideline on management of dental patients with special health care needs. Pediatr Dent 2012; 34 (special issue):16.
3. American Academy of Pediatric Dentistry. Policy on transitioning from a pediatric-centered to an adult-centered dental home for individuals with special health care needs. Pediatr Dent 2012; 34 (special issue):16.
4. American Academy of Pediatric Dentistry. Symposium on lifetime oral health care for patients with special health care needs. Pediatr Dent 2007; 29 (2): 92-152.
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