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In My Opinion |
Submitted for publication 03/23/04; accepted 06/06/04
The purpose of this editorial is to advocate the development of a career path within the field of Special Needs Dentistry. After a brief historical overview, the status of specialty training and certification in Special Needs Dentistry in the United States, Great Britain, Australia, and New Zealand will be reviewed including descriptions of recently developed training and credentialing programs.
In 1981, under the auspices of the American Dental Association, the journals of the American Association of Hospital Dentists, the Academy of Dentistry for Persons with Disabilities (formerly Academy of Dentistry for the Handicapped), and the American Society for Geriatric Dentistry were merged to form a single journal: Special Care in Dentistry. This was the first time the term "special care" was used within the profession. In 1987, Paul Van Osterberg’s vision led to the birth of the Federation of Special Care Organizations in Dentistry.1 In the United States, Special Care Dentistry has been described as "an approach to oral health management tailored to the individual needs of people with a variety of medical conditions or limitations that require more than routine delivery of care"; it "encompasses preventive, diagnostic, and treatment services."2 Glassman and Miller in 1998 proposed that patients with "special needs" referred to "medical, social, psychological, or physical conditions that make it necessary to modify the normal course of dental treatment. Examples of such conditions include medical and developmental disabilities, problems associated with aging and psychological problems."3 Special Needs Dentistry is defined by the Royal College of Surgeons of Edinburgh as "the specialty of dentistry concerned with the oral health care of patients with special needs for whatever reason including those who are physically or mentally challenged."4 The definition of Special Needs Dentistry used in Australia and New Zealand (the Royal Australasian College of Dental Surgeons) is "that part of dentistry concerned with the oral health of people adversely affected by intellectual disability, medical, physical, or psychiatric issues."5 As they evolved, the terms "Special Care Dentistry" and "Special Needs Dentistry" became essentially synonymous.
Over the past ten years, there was growing consensus that a career structure was needed for persons working in the field of Special Needs Dentistry.6 By 2000, professional groups dedicated to Special Needs Dentistry had been established in the United States, Great Britain, Australia, New Zealand, and several nations in Europe and South America.7–9 That year, at the XV Congress of the International Association of Disability and Oral Health in Spain, there was a lengthy debate about developing a career structure for people working in the field. This meeting included a diverse group of dentists and hygienists from hospital dentistry, pediatric dentistry, and community dentistry from Great Britain, Europe, and Australia.
The various definitions convey that Special Needs populations have a variety of disabilities, and evidence exists that they are at high risk for developing oral diseases and conditions and experience significant barriers to accessing dental care. The U.S. surgeon general’s report on oral health discussed the inequalities and disparities that affected vulnerable populations such as the disabled, medically compromised, and elderly concerning untreated dental disease, access to dental care, and use of preventive services.10 The surgeon general’s report also discussed the need for educating dental and other health care providers in the care of such patients, using a coordinated and integrated approach to their dental and medical care. However, there clearly is a lack of formal training for dentists in U.S. undergraduate and postgraduate dental curricula in the field of dentistry for people with special needs. For individual dental professionals in the United States working with patients with special dental needs, there is no adequate career pathway or recognition of their "special" skills, and therefore, they cannot currently be considered a "specialist."
In the United States, there have been fellowship programs in Hospital Dentistry, Geriatric Dentistry, and Dentistry for Persons with Disabilities for more than twenty years, but these programs have not attained recognition by the ADA or by academia. In Hospital Dentistry, there are General Practice Residencies associated with hospitals, which are of a one-or two-year duration. However, there is no stepwise career structure developed for persons teaching and working within the hospital system. The majority of training in Dentistry for Persons with Disabilities has been through the field of Pediatric Dentistry, but again there is no established career structure for nonpediatric dentists working in institutional settings who provide care for adult patients with Special Needs. Geriatric Dentistry is really the "youngest" member of the group; the most established training program in geriatric dentistry is at the University of Minnesota.11,12 In the 1980s, the Veterans Administration had a multisite training program that produced many of the current leaders in Geriatric Dentistry. Since the closure of that program in 1992, the Health Resources and Services Administration (HRSA) has promoted joint fellowships in medicine and dentistry, which are still in existence today. Generally, five or so HRSA two-year geriatric dentistry fellowship programs have been funded concurrently.12 However, there is no established career structure for people graduating from these fellowship programs unless they also complete a master’s degree in Public Health, Dental Public Health, or similar area.11,12 As Lamster recently stated in an editorial in the American Journal of Public Health, "there is no obvious support for training a new group of ‘gerodontologists.’"13
The National Foundation of Dentistry for the Handicapped, founded in 1974 with support from the American Dental Association, is an organization that helps link disabled and medically compromised elderly with dentists in their community to receive free dental services. There is no training program for the many volunteer dentists who donate their time to this service, nor is there any certification process.14 The American Academy of Developmental Medicine and Dentistry, founded in 2002, was established to increase knowledge and experience of dentists and physicians by improving training at medical and dental schools. A model of this training program has been developed at the University of Louisville.15
In the United States, there are no specifically trained or credentialed dental providers who address the comprehensive needs of the population of adult patients with Special Needs. In contrast, pediatric dentists are credentialed and specifically trained dental providers to care for the many children with Special Needs.16,17 The American Academy of Pediatric Dentistry defines the specialty of Pediatric Dentistry as "an age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs."16 However, it seems that a variety of individuals are increasingly being called upon to provide dental care to adult patients with Special Needs. These include trainees in programs and fellowships such as General Practice Residency, Advanced Education in General Dentistry, Geriatric Dentistry, Pediatric Dentistry, and Oral Medicine, together with those dental professionals who have accumulated clinical expertise in the care of adult patients with complex medical situations. Thus, there is no clearly identifiable continuum of dental care for the transition of pediatric patients with Special Needs into adulthood and their older years. Some persons with Special Needs need access to sedation and general anesthetic services and in the United States have traditionally utilized the services of the hospital-affiliated training programs. Additionally, more and more hospitals in the United States are requiring dentists to be board-certified in order to obtain hospital credentialing. Hospitals understand the title "board-certified" or "Diplomate" because all physicians are required to obtain board certification within a certain time period after applying for hospital privileges. The term "fellow" means very little to hospital administrators, so it has become necessary to provide medically equivalent credentials for qualified dentists that attest to their training, experience, education, and knowledge to obtain hospital, academic, federal, and state privileges. The Special Care Dentistry board has recently endorsed the development and credentialing of qualified dentists and fellows as Diplomates in Special Care Dentistry, with the formation of a certifying board.18 The first candidates will be examined at the 2004 annual meeting, which will be held in Calgary in association with the International Association of Disability and Oral Health.
Great Britain has approached the delivery of care and training of dentists to care for Special Needs patients quite differently.19 There, the majority of persons with profound disabilities that prevent them from accessing care in a regular dental practice are treated by the Community Dental Service (CDS). The CDS is a salaried primary dental care service that accepts referrals from many sources: dental colleagues, all levels of health care professionals, social services, family and professional caregivers, and individual patients themselves. Potential patients must fulfill local acceptance criteria, which encompass the usual Special Needs Dentistry categories. Domiciliary care is offered to individuals with significant mobility problems. Sedation and, in many localities, general anesthesia services are provided.
Although many of the 1,800 CDS dentists have acquired considerable skill and expertise in treating patients with profound disabilities and are in effect specialists in Special Needs Dentistry, there is no formal training pathway leading to professionally recognized specialist status. The dental profession, while increasingly recognizing the need for such education and training, has been divided about the way forward. The Joint Advisory Committee on Special Care Dentistry, which was created to consider the merits of establishing a new specialty, has proposed a training program. There has also been much discussion about whether existing specialties already meet the needs of Special Care patients—although the experience of dentists actually treating the majority of patients with disabilities would indicate otherwise. A substantial number of existing specialists in Great Britain now support the creation of a Special Care Dentistry specialty. Discussions continue.
Several programs do offer training in Special Needs Dentistry in Great Britain. For example, Eastman Dental Institute in London and King’s College of London both offer a one-year master of science degree (M.Sc.) in Special Needs Dentistry. There is also a distance-learning module on Special Needs Dentistry that forms part of Bristol University’s program of Open Learning for Dentists (BUOLD), which leads to a Diploma in Postgraduate Dental Studies. The Royal College of Surgeons of England offers an examination leading to a Diploma in Special Care Dentistry.19,20 Recently, the Royal College of Surgeons of Edinburgh has begun offering a similar examination process whereby the successful candidate receives a Diploma of Membership in Special Needs Dentistry.4 Indeed, to improve their qualifications and career pathway in Special Needs Dentistry, several U.S. candidates have successfully attained this diploma from the Royal College of Surgeons of Edinburgh.
In Australia and New Zealand, Special Needs Dentistry has become a registered specialty of dentistry in recent years, and several academic specialty training programs have been established.21 Several dentists have been recognized as specialists in Hospital/Special Needs Dentistry in New Zealand. There is an M.D.S. program in Hospital Dentistry at the University of Otago, plus another specialty postgraduate Special Needs program in development. In Australia, both the University of Adelaide and the University of Melbourne have established a three-year Clinical Dentistry Doctoral Degree in Special Needs Dentistry. In November 2003, the Australian Dental Council recognized the specialty of Special Needs Dentistry, which in turn has now been legislated in one state and is pending in other states. Thus, Australia and New Zealand are some of the first countries to recognize Special Needs Dentistry as a registerable dental specialty.
The New Zealand Society of Hospital and Community Dentistry (NZSHCD) has been well established, holds regular national clinical meetings, and is composed mainly of public dental officers in New Zealand hospitals.21 The Australian Society for Special Care in Dentistry (ASSCID) evolved over the last decade as an affiliate professional organization of The Australian Dental Association.21 Importantly, not only has clinical care provision for patients with special needs been an identified focus of these groups, but advocacy for education, research, professional development, and policy issues have had a clear focus. An innovative initiative by ASSCID in 2004 was the Australasian Special Needs Dentistry Mentoring Masterclass, supported by Colgate Oral Care and Alzheimer’s Australia (SA). This initiative has been identified as a key catalyst for promoting Special Needs Dentistry in Australia and New Zealand by supporting and mentoring dental professionals working in the field along their career paths. Similar to the college diploma initiatives in the field in Great Britain, the Royal Australasian College of Dental Surgeons (RACDS) established a Special Field Examination in Special Needs Dentistry (FRACDS [SND]). Examinations were held in 2002 and 2003. Further examination and application details can be obtained on the college’s website.5
In the United States, the institution of the Special Care Dentistry Board Certification and Credentialing of Diplomates will, in 2004, identify a group of highly trained dental professionals in Special Care Dentistry and help create a career path in the field. It will be interesting to see if organized dentistry and academia will accept these credentials so that specialty recognition and a definitive career structure can be developed in the United States. Colleagues in Great Britain are hopeful that they will soon approach a similar stage as Australia and New Zealand.
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REFERENCES |
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This article has been cited by other articles:
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  H. B. Waldman and S. P. Perlman A special care dentistry specialty: sounds good, but . . . J Dent Educ., October 1, 2006; 70(10): 1019 - 1022. [Full Text] [PDF]
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L. P. Dao, S. Zwetchkenbaum, and M. R. Inglehart General Dentists and Special Needs Patients: Does Dental Education Matter? J Dent Educ., October 1, 2005; 69(10): 1107 - 1115. [Abstract] [Full Text] [PDF]
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