Just like everyone else, patients with special needs must have regular dental care to maintain healthy teeth and gums. However, finding dentists with the training necessary to help them hasn’t always been easy — or, in some cases, even possible. But thanks to stronger accreditation standards from the American Dental Association (ADA), along with more mainstream understanding of people with disabilities, dental schools around the country are working to improve this kind of care.
[Above: Lynne Taiclet and her students travel to Richmond, Va., during a service trip where they provide free dental care for athletes involved in the Special Olympics state summer games alongside students and faculty from Virginia Commonwealth University.]
At the University of Pittsburgh School of Dental Medicine (SDM), the Center for Patients with Special Needs (CPSN) offers oral care for individuals whose disabilities make regular dental care problematic. Lynne Taiclet, DMD, the center’s director and assistant professor with the school, specializes in treating adult patients with physical, emotional, cognitive, and sensory impairments.
While SDM has a separate department for pediatric patients with disabilities, Taiclet says adult patients with special needs face significant barriers when it comes to obtaining basic services. In some states, Medicaid doesn’t cover adequate dental services for these individuals, while even those with good coverage must contend with a shortage of dentists who are specially trained.
“There are many of these patients across this country who have nowhere to go. It’s heartbreaking,” Taiclet says.
In recent years, the American Dental Association’s Commission on Dental Accreditation (CODA) has focused on addressing this shortage by implementing standards for dental school graduates to be competent in assessing patients with special needs — meaning a graduate should be able to diagnose or recommend the patient to another practitioner if he or she is unable or unwilling to treat the patient.
At CPSN, students learn how to serve patients across a broad spectrum of disabilities and conditions. At the center, students take a course on treating individuals with developmental, intellectual, psychiatric, and acquired disabilities, and also have comprehensive clinical rotations. The rotations allow them to practice using accommodations and techniques for specific patient needs. People with cerebral palsy, for example, usually remain in wheelchairs during an appointment instead of being transferred to a dental chair, Taiclet says. Sometimes dentists can sit while treating these patients, but often they must remain standing and might even need to twist in uncomfortable positions to provide care.
SDM is unique in its ability to offer such intense training because providing care for patients with disabilities has long been a part of the school’s history, and Pennsylvania’s Medicaid program covers many dental services for these individuals. While dental schools across the country seek to prepare a workforce that is competent in caring for this underserved population, university and state resources can make it difficult, Taiclet says.
“Sometimes these patients aren’t Medicaid eligible, but even if they were, [these services] wouldn’t be covered,” Taiclet says. The extent to which a state supports dental care for underserved citizens can be a determining factor in a school’s ability to serve special needs patients and to provide this important training for students, she adds.
With patients on the autism spectrum who are sensitive to sounds and light, sunglasses might be used during a procedure or they might listen to music with an iPad and earbuds. Instead of telling a patient to turn this way or that or to open his or her mouth wider, the dentist might use hand signals instead. In some cases, dentists will sing or read to agitated patients to help calm them down, as is often done in pediatric dentistry, or dim the lights during a procedure to set them at ease. And more combative patients might need to be sedated before they even arrive for their appointments. These issues and more are what have made finding specialized dental services so difficult for struggling families nationwide.
That is a familiar story for Michelle Ziegler, DDS, who serves as director of special-care dentistry and director of advanced education in general dentistry at the Medical University of South Carolina.
The school’s Clinic for Adolescents and Adults with Special Health Care Needs accepts Medicaid patients and some with private insurance, but fees are charged for anything not covered by these plans. Ziegler says the clinic is the only dedicated facility providing a wide array of outpatient services besides a handful of residential facilities and private practices statewide. Because of that, people often face a two- to three-month waiting period for appointments.
Third- and fourth-year students complete rotations at the clinic in which they learn to deal with issues less common in regular dental practice. For example, says Ziegler, while it might take 30 to 45 minutes for a typical teeth cleaning, the time needed to care for a special-needs patient can be double that. When time is already at a premium, it is important that students learn how to adapt. In some cases, behavioral techniques that help calm or redirect might be needed, or if sensory issues are a challenge, hand instruments might be used to avoid noises and vibrations. If a patient has uncontrolled movements or needs his or her mouth propped open, more assistants will be needed to help during a procedure, even if it is a relatively simple one.
The clinic has three dental operating suites and a room with a wheelchair lift, and everything is designed to be wheelchair and stretcher accessible. Not only are basic services offered, such as cleanings and X-rays, but so are restorative dentistry, endodontics and oral surgery services. The hope is that students will use what they learn after they graduate because, Ziegler says, about 80 percent of special needs patients can be worked into a mainstream practice if a dentist knows how to treat them.
“The students have always received didactic information regarding the management of patients with a variety of special healthcare needs,” she says, “However, research has shown that hands-on clinical experiences increase the likelihood of a provider to continue to offer services to this patient population in practice.”
And to help with making specialized care more widely available in South Carolina, Ziegler and her colleagues have developed an online database called the Special Needs Directory of Dentists (S.A.N.D.S.), which lists dentists statewide who accept patients with special needs. It is searchable by name and the conditions each dentist can handle and includes a tab with information about payment options. “It is our hope that this database will become larger and larger in terms of availability for patients,” she says.
She also hopes more and more of her dental school graduates will become dentists listed in the database.— a reasonable expectation. “Our students graduate with a greater appreciation for the needs of this population and how to navigate through the system,” Ziegler says.
Lindsay Jones is a contributing writer for INSIGHT Into Diversity. To learn more about S.A.N.D.S., visit sandsc.org. This article ran in our May 2018 issue.