J Dent Educ. 70(10): 1019-1022 2006
© 2006 American Dental Education Association
A Special Care Dentistry Specialty: Sounds Good, But . . .
H. Barry Waldman, D.D.S., M.P.H., Ph.D.;
Steven P. Perlman, D.D.S., M.Sc.D.
Submitted for publication 06/19/06;
accepted 07/26/06
In December 2005, "the General Dental Council of Great Britain approved, in principle, the establishment of a specialty of Special Care Dentistry."1 An earlier commentary in the Journal of Dental Education similarly advocated in the United States for "the institution of the Special Care Dentistry Board Certification and Credentialing of Diplomates . . . [to] identify a group of highly trained dental professionals . . . and help create a career path in the [Special Care Dentistry] field."2 Is this an idea whose time has come, or are there negative aspects to this concept that should make us more cautious?
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Demographics
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There is no doubt an increasing need for the involvement of more dentists in the provision of oral health services for the burgeoning population of individuals with a wide range of special health care needs. For example, the U.S. Census Bureau reported that, in 2002, 51.2 million noninstitutionalized civilian residents of all ages (18.1 percent of the population) had some level of disability and 32.5 million (11.5 percent of the population) had a severe disability.3 The disability rate increased with age: ranging from 8.4 percent for the population less than fifteen years to 71.7 percent for those eighty years and older (Table 1
). In 2004, more than 23 million residents had two or more disabilities4 (Table 2).
In 2004, the proportion of residents with disabilities represented more than half of the population sixty-five years and older of West Virginia and Mississippi. Variations in the proportion of the population with disabilities by state ranged widely:
- age five to twenty years: Connecticut at 4.5 percent to Maine at 10.4 percent;
- age twenty-one to sixty-four years: New Jersey at 9.1 percent to West Virginia at 21.5 percent;
- age sixty-five years and older: Nevada at 33.3 percent to Mississippi at 52.1 percent.5
The realities of the increasing prevalence of disabilities in older ages and the need for services for individuals with special needs must be considered in terms of the dramatic projection for a time in the not too distant future when the baby-boomer generation will represent one in five members of the population. By the year 2030, there will be more than 71 million residents sixty-five years and older in the United States. The sixty-five plus population will represent more than one in four of the residents in six states (North Dakota, Montana, New Mexico, Wyoming, Maine, and Florida—ranging between 25.1 and 27.1 percent; see Table 3).6
The necessity to prepare for these demographic developments was acknowledged by the Commission on Dental Accreditation in its adoption of new standards for dental and dental hygiene education programs to ensure didactic and clinic opportunities to better prepare dental professionals for the care of individuals with particular and extraordinary requirements.7 The standard states: "Graduates must be competent in assessing the treatment needs of patients with special needs." Implementation of this revised standard was required by January 2006. Specifically, "patients with special needs" was defined in these standards as "those patients with medical, physical, psychological, or social situations that make it necessary to modify normal dental routines in order to provide dental treatment for that individual. These individuals include, but are not limited to, people with developmental disabilities, complex medical problems, and significant physical limitations."8
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The Current Situation
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The U.S. Department of Health and Human Services (HHS) in The National Survey of Children with Special Care Needs, Chart Book 2001 observed: "The service most commonly reported as needed but not received was dental care: more than 8 percent of children with special health care needs needed but did not obtain this service."9 Although HHS conducted a nonexamination national telephone interview study to determine the health and social needs of children with special health care needs, no national studies have been conducted to determine the actual prevalence of oral diseases among various populations with intellectual/developmental and other disabilities. Numerous local and regional reports, however, provide an appreciation of the needs. The population with intellectual and other disabilities has significantly higher rates of poor oral hygiene, gingivitis, and periodontitis than do members of the general population. Although caries rates among people with disabilities vary widely, their overall rates are higher than that of the general population.10,11
Hundreds of thousands of children and adults with disabilities have or will "age out" of Medicaid dental services, which is a critical financial program for many lower-income individuals with disabilities. The litany of reasons for dental practitioner non-participation in the Medicaid dental program (e.g., inadequate compensation, contentious paperwork, appointment no-shows, and perceptions of professional responsibility among dentists) pales in comparison to the reality that increased numbers of adults in need of services will not be eligible for care. As federal and state governments attempt to deal with the "red ink" of budget deficits and the demands for improvements in the Medicare and Social Security programs, it is all too easy to neglect needed but nonstatutory required health services—specifically, dental care for adults.12
The reality is that current federal, state, and local government support for dental services accounts for about 5 percent of overall dental expenditures (with limited change projected for the future) compared to 43 percent for total personal health expenditures, 59 percent for hospital costs, and 27 percent for physician care. The proportion of total expenditures for dental services covered by government agencies is smaller than the government’s share of expenditures for all major health care services.13
The recent changes in dental school accreditation standards to require increased didactic and clinical opportunities for new dental and dental hygiene graduates to provide services to individuals with special needs hopefully will prepare increasing numbers of (willing?) practitioners to provide services. In the meantime, thousands of current practitioners—with claims of limited training—may continue to be reluctant to provide care.
In 2004, there were 174,430 professionally active dentists in the country (including 1,552 in Puerto Rico) ranging from 266 in Wyoming to 26,692 in California.14 The number of active dentists has almost peaked. As the anticipated number of dentists retiring rises above the number of dental school graduates, the total number of dentists in the country will begin a slow decline. In actuality, since the late 1980s, the dentist-to-population ratio has been falling, and "by 2020, the dentist-to-population ratio could be comparable to the ratio experienced during World War I."15 An added factor is the increasing proportion of female practitioners in the workforce. Dental school enrollment trends indicate that female participation in the dental workforce should increase from the current level of 19 percent to 30 percent in 2020. This is significant because one study found that
In 1999, female dentists younger than 40 years old were at least five time more likely to work part-time than their male counterparts (31.3% vs. 5.6%). Female dentists between the ages of 40 and 59 were more than three times more likely to work part-time than males (28.6% vs. 8.7%). . . . the impact on the dental workforce will be significant if gender differences in work status persist.15
In summary:
- There are great numbers of individuals with a wide range of special needs, and the potential proportion in the general population will increase dramatically with the further aging of the baby-boomer generation, most of whom will be dependent upon local practitioners for health services.
- Changes in educational requirements for dental professionals should better prepare new graduates for needed care, but the limited formal training of current practitioners may result in the continued reluctance of some to provide services.
- Many of the individuals with special needs are in need of added dental care.
- Continuing decreases in the dentist-to-population ratio (and the potential added impact of an increasing workforce of part-time female dentists) could maintain or increase current levels of practice busyness.
- Inadequate third-party coverage is a continuing impediment for practitioner involvement in the care of individuals who often require added chair time and provider effort.
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So Why Not a Specialty of Special Care Dentistry?
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There is an unquestionable need for increased knowledge, abilities, and willingness among a greater number of dental practitioners to provide services for a seemingly endless and growing array of individuals with special needs. Advanced training and abilities are essential in the schools of the profession and in the private offices of practitioners—not that different from the need to improve the abilities of medical practitioners to provide care in the general realm of geriatric care. But in an effort to enhance the dental profession’s ability to meet the needs of this burgeoning population, we must not lose sight of the reality that, as with other clinical dental specialties, the burden of providing the major component of care must fall upon the general practitioner. It would be all but impossible to anticipate a few score or even hundreds of special care specialists to assume all the needed care for tens of millions of individuals, including (as defined by the Commission on Dental Accreditation) "those patients with medical, physical, psychological, or social situations that make it necessary to modify normal dental routines in order to provide dental treatment for that individual."8
There is concern that "more and more hospitals in the United States are requiring dentists to be board-certified in order to obtain hospital credentialing."2 However, hospital credentialing in many instances is likely to be based upon performance capabilities as defined by the chief of a discipline and not necessarily based upon board specialization in a new area.
In the realm of other specialty components of care (be it endodontics, orthodontics, pediatric dentistry, periodontics, prosthodontics, oral surgery, or oral radiology), there are professional and financial incentives for general practitioner involvement. Is it any wonder that many practitioners are reluctant to provide needed care given the following conditions: 1) decreasing dentist-to-population ratios, 2) an increasing part-time workforce and reasonable practice busyness conditions, 3) limited if any formal educational preparation to care for special needs patients, 4) particularly limited financial incentives for practitioners to acquire a specialty certification in special needs dentistry in this era of favorable dental practice economics, and 5) the potential of added intrusions into practice dynamics and the increased complexities of care for individuals with intellectual/developmental and other disabilities? Would the establishment of this new specialty only reinforce the sentiment "Let someone else do it"?16
On the other hand, should specialists in geriatric dentistry (if one were to be recognized) and specialists in special care dentistry be encouraged to move from Pennsylvania to West Virginia, followed by a move to Maine? According to U.S. Census Bureau projections, these states will have the second highest proportions of older residents, undoubtedly with increased levels of disabilities during the next decades (Table 3
). Or is enhancing the abilities of general practitioners to provide the needed care with adequate financial remuneration a more realistic approach?
The dental profession has been rightfully reluctant to gerrymander components of services into an extended number of specialties, relying instead upon the need to enhance the preparation of its members to provide a broad spectrum of services. Given the realities of providing care to burgeoning populations of individuals with special needs, the most prudent approach is to follow the same path, but with the added effort to lobby for enhanced financial support for services provided to our nation’s rapidly growing special needs population. Essentially, instead of "Let someone else do it," "Let us all do it!"
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Footnotes
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Dr. Waldman is Distinguished Teaching Professor, Department of General Dentistry, School of Dental Medicine, Stony Brook University; Dr. Perlman is Global Clinical Director, Special Olympics, Special Smiles, as well as Associate Clinical Professor of Pediatric Dentistry, Boston University Goldman School of Dental Medicine, and in private practice in Lynn, MA. Direct correspondence and requests for reprints to Dr. H. Barry Waldman, Department of General Dentistry, School of Dental Medicine, Stony Brook University, Stony Brook, NY 11794-8706; 631-632-8883 phone; 631-632-3001 fax; hwaldman{at}notes.cc.sunysb.edu.
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REFERENCES
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- Fiske J. Special care dentistry (editorial). Br Dent J 2006; 200(2):61.[Medline]
- Ettinger RL, Chalmers J, Frenkel H. Dentistry for persons with special needs: how should it be recognized? J Dent Educ 2004; 68:803–6.[Free Full Text]
- Steinmetz E. Americans with disabilities: 2002. Washington, DC: Department of Commerce, U.S. Census Bureau, 2006.
- U.S. Census Bureau. American factfinder: sex by age by number of disabilities, Table B18001. At: http://factfinder.census.gov. Accessed: June 15, 2006.
- U.S. Census Bureau. American factfinder: United States and states, Table R1801. At: http://factfinder.census.gov. Accessed: June 15, 2006.
- U.S. Census Bureau. Interim projections, 2005: population under age 18 and 65 and over: 2000, 2010, and 2030. At: http://census.gov/population/www/projections/projectionsagesex.htm. Accessed: June 15, 2006.
- Waldman HB, Fenton SJ, Perlman SP, Cinotti DA. Preparing dental graduates to provide care to individuals with special needs. J Dent Educ 2005; 69:249–54.[Abstract/Free Full Text]
- Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, June 30, 2004.
- U.S. Department of Health and Human Services. The national survey of children with special care needs, chart book 2001. Rockville, MD: Maternal and Child Health Bureau, 2004.
- White BA, Caplan DJ, Weintraub JA. A quarter of a century of changes in oral health in the United States. J Dent Educ 1995; 59:19–60.[Abstract]
- 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, 2000.
- Waldman HB, Perlman SP. Children with disabilities are aging out of dental care. J Dent Child 1997; 64:385–90.[Medline]
- Heffler S, Smith S, Keehan S, et al. U.S. health spending projections for 2004–2014. Health affairs. Web exclusive. W5:74–85. February 23, 2005. At: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&adopt=Abstract&lists_uids=15728678&itool=iconabstr&query_hl=2&itool=pubmed_docsum. Accessed: January 12, 2006.
- The Henry J. Kaiser Family Foundation. Number of dentists, 2004. At: www.statehealthfacts.org. Accessed: May 24, 2006.
- Solomon ES. The future of dentistry. At: www.etsdental.com/articles/future2.htm. Accessed: June 5, 2006.
- Waldman HB, Perlman SP. Why is providing dental care to people with mental retardation and other developmental disabilities such a low priority? Public Health Rep 2002; 11:435–9.
Top
Demographics
The current situation
