|Year : 2016 | Volume
| Issue : 1 | Page : 42-44
Break the barrier: Bringing children with special health care needs into mainstream dentistry
Dhanalakshmi Ravikumar, S Sujatha
Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Chennai, Tamil Nadu, India
|Date of Web Publication||7-Sep-2016|
Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, 162 Poonnamalle High Road, Chennai - 600 095, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Dental treatment is the most common unmet need for children with special health care needs, as they present with a complex assay of developmental delays and unusual issues, all of which can complicate routine dental examination and treatment. It is a greater challenge for the dentist to treat children with special health care needs (SHCNs) and special arrangements to provide dental care for these patients. This review paper highlights about different barriers encountered by the children with SHCNs, their parents, and the dentist and possible ways of breaking the barriers.
Keywords: Barriers, dental treatment, special health care needs
|How to cite this article:|
Ravikumar D, Sujatha S. Break the barrier: Bringing children with special health care needs into mainstream dentistry. Int J Pedod Rehabil 2016;1:42-4
|How to cite this URL:|
Ravikumar D, Sujatha S. Break the barrier: Bringing children with special health care needs into mainstream dentistry. Int J Pedod Rehabil [serial online] 2016 [cited 2019 Feb 23];1:42-4. Available from: http://www.ijpedor.org/text.asp?2016/1/1/42/190000
| Definition|| |
The American Academy of Pediatric Dentistry defines special health care as "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 programs. 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 special needs requires specialized knowledge acquired by additional training as well as increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine." 
Dental treatment is the most common unmet need for children with special health care needs (SHCNs), as they present with a complex assay of developmental delays and unusual issues, all of which can complicate routine dental examination and treatment. Children with SHCNs suffer from both poor oral health and problems in accessing dental care services.  Children with SHCN may express a greater anxiety about the dental visit and dental treatment than those without a disability, which may have an adverse effect in the frequency of dental visits and subsequent oral health.  Dental visits are important to prevent dental decay and more serious consequences of oral disease for children with SHCN. Untreated oral disease can lead to pain, abscesses, and systemic health problems. These factors stress the importance of accessing dental care.
Children with SHCN may have different diagnoses and conditions but they have an important and common needs.  It is a greater challenge for both the pediatric dentist and the general dental practitioner to treat the special children in general practice due to several environmental and nonenvironmental barriers.
| Common Conditions Encountered in Daily Practice|| |
Several health conditions are encountered every day in routine dental practice; however, providing dental care for children with developmental disabilities becomes complicated as it is time-consuming and costly. However, it can be accomplished with increased awareness of the disability and its associated medical condition, knowledge of the disability, and incorporating flexibility and creativity in the office setting. 
The common conditions encountered are autism spectrum disorder, Down syndrome, cleft lip/palate, intellectual disability attention deficit hyperactivity disorder leukemia, developmental disabilities, hemophilia, sickle cell anemia, and Von Willebrand disease.
| Common Barriers Encountered|| |
McIver described five key barriers to access dental care for children with SHCNs. The key barriers were: (1) The primary medical care system; (2) the child's parents; (3) the child himself; (4) the dentist; and (5) payment for dental care.
The primary medical care system
The primary medical care becomes a major barrier for the children with SHCN as the child has other more urgent health care needs.
The child's parents perceive many barriers as the treatment of their child becomes time-consuming and highly expensive. McIver had stated that the child's parents face problems to find a dentist nearby to treat their child and, moreover, to find a dentist, who is ready to treat their child with the present medical condition. Since some parents believe that the child has baby teeth and it falls on its own, this is further complicating the child's oral health. 
The child himself
The child himself becomes a major hindrance to deliver a proper dental care as the child is afraid of the dentist and cannot behave cooperatively.
The dentist becomes a barrier because of his/her inadequate knowledge and clinical experience. Dao et al. and Waldman and Perlman had stated that apart from educational factors, several additional noneducational factors, such as special arrangements, needed to provide dental care for these patients and concerns about adequate compensation might also affect dentists' willingness to treat special needs patients. ,
Payment for dental care
Payment for dental care becomes a major barrier because it is too expensive and most dentists will not accept child's dental insurance. The child's other medical expenses add an additional burden to their parents. Currently, most of the insurance companies offer limited coverage for a few dental procedures under general health insurance plans. Most insurance covers only for dental treatment involving 24-h hospitalization or life-threatening situations. There is no comprehensive stand-alone for dental treatment.  If dental insurance is made available for all, especially for children with SHCN, it will reduce the burden and expense of the future dental treatment.
Common problems encountered while treating special health care needs children in general dental setup
Behavioral problems can interfere with the oral examination for those who lack language comprehension, unusual sensory responses, unable to learn new information due to decreased cognitive development, aggressive behavior of the child, inattention, hyperactivity, and restricted behavior. All these problems can lead to a significant barrier to deliver a proper oral care.
Is it possible to break the barrier?
Several barriers were encountered to manage the special children in general dental practice. However, it is possible to break the barrier and to bring the special need children into the mainstream dentistry.
How to break the barrier?
It is imperative to educate dental students in the diagnostic needs and provision of dental care. Special arrangements should be available in the general dental practice/in pediatric practice to treat the child immediately. The pediatric dentist/general dentist should be aware of various behavioral techniques unique to each special child.
An accurate comprehensive and up-to-date medical history should be evaluated for correct diagnosis and effective treatment planning. Changes in medications should be documented during each visit. Parent, family member, or caretaker may need to be present to facilitate communication and/or provide information that the patient cannot. Maintain a consistency while treating the special children by having the same dentist and a same operating room to familiarize the patient and giving early morning appointments. Utilization of audiovisual aids with social story which is written from a child's perspective that describes a social situation, person, or concept that teaches the child how to manage his/her behavior during a given social situation (for example during dental treatment) by describing it with the pictures relevant to the situation and simple text. This will familiarize and prepare the children for the upcoming dental visits.  Protective stabilization can be helpful in patients for whom traditional behavior guidance techniques are not adequate.
Parental awareness and early preventive measures
Dental disease in children can lead to serious general health problems and significant pain, interference with eating, overuse of emergency rooms.  Parents of children with disabilities can be isolated, not receiving the support and information necessary to enable them to access oral health care.  The greatest obstacle faced by most of the parents in rendering dental services to their children was a lack of awareness.  Routine check-up and health education programs can be implemented on a regular basis to educate caregivers/teachers at special school centers. To emphasize the need for preventive dental care which needs to be started at an early age to aim at primary dentition and later for the permanent dentition.
The provision of high-quality restorative treatment to children with SHCN is difficult due to the patient's ability to cooperate with the treatment and poor muscle coordination such as drooling and tongue movement may compromise high-quality restorative procedures. Sedation or general anesthesia may be a treatment of choice but these techniques have their own problems in terms, cost, and patient morbidity and mortality. 
Several preventive strategies such as noncariogenic diets, application of topical fluoride, and sealants would be beneficial to prevent from further dental complications.  Atraumatic restorative treatment approach might help in treating children with poor muscle coordination. 
Does the dental education matters?
Researches have found that not all dentists feel prepared to treat patients with special needs due to lack of knowledge and clinical experience. , It is important that the dental schools should educate their students in the diagnosis of treatment needs and provision of care for patients with SHCNs. The dental schools should evaluate how satisfied the students are when treating the special children and what are all the challenges they are perceiving.  The dental colleges should have a link with various special schools/homes to educate the students, and as it is a multidisciplinary approach to treat the special need children, the institution should have a link with different specialties in the hospitals.
| Conclusion|| |
Even though several options are available to treat the special need children in the mainstream dentistry, it still remains a greater challenge for the pediatric dentist/general dentist to treat them with the current knowledge status and available clinical experience. If all the above criteria are implemented in the dental institutions and the private practice, it will be a milestone to step ahead to treat the children with SHCNs in the mainstream dentistry. "Break the barrier and don't say no to treat the children with the special health care needs."
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Academy of Pediatric Dentistry. Reference Manual Overview: Guideline on Management of Dental Patients with Special Health Care Needs. Clinical guidelines 2006;37:166-71.
Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
Peltier B. Psychological treatment of fearful and phobic special needs patients. Spec Care Dentist 2009;29:51-7.
Nelson LP, Getzin A, Graham D, Zhou J, Wagle EM, McQuiston J, et al.
Unmet dental needs and barriers to care for children with significant special health care needs. Pediatr Dent 2011;33:29-36.
Charles JM. Dental care in children with developmental disabilities: Attention deficit disorder, intellectual disabilities, and autism. J Dent Child 2010;77:84-91.
McIver FT. Access to care: A clinical perspective. In: Mouradian W, editor. Proceedings: Promoting Oral Health of Children with Neurodevelopmental Disabilities and Other Special Health Care Needs: A Meeting to Develop Training and Research Agendas, Center on Human Development and Disability. Seattle, Washington: University of Washington; 2001. p. 167-71.
Dao LP, Zwetchkenbaum S, Inglehart MR. General dentists and special needs patients: Does dental education matter? J Dent Educ 2005;69:1107-15.
Waldman HB, Perlman SP. Mandating education of dental graduates to provide care to individuals with intellectual and developmental disabilities. Ment Retard 2006;44:184-8.
Ahuja NK, Parmar R. Demographics and current scenario with respect to dentists, dental institutions and dental practices in India. Indian J Dent Sci 2011;3:8-11.
Casamassimo PS, Thikkurissy S, Edelstein BL, Maiorini E. Beyond the dmft: The human and economic cost of early childhood caries. J Am Dent Assoc 2009;140:650-7.
Department of Health. Valuing people: A new strategy for learning disability for the 21 st
century. London: Department of Health; 2001.
Hegde AM, Babu AA, Mohammed A, John A, Singh K, Preethi VC, et al
. Special needs of special children parental view. Nitte Univ J Health Sci 2015;5:2249-7110.
Molina GF, Faulks D, Frencken J. Acceptability, feasibility and perceived satisfaction of the use of the atraumatic restorative treatment approach for people with disability. Braz Oral Res 2015;29. pii: S1806-83242015000100292.
Krause M, Vainio L, Zwetchkenbaum S, Inglehart MR. Dental education about patients with special needs: A survey of U.S. and Canadian dental schools. J Dent Educ 2010;74:1179-89.