The value of education in special care dentistry as a means of reducing inequalities in oral health
Dublin Dental University Hospital
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People with disability are subject to inequality in oral health both in terms of prevalence of disease and unmet healthcare needs. Over 18% of the global population is living with moderate to severe functional problems related to disability, and a large proportion of these persons will require Special Care Dentistry at some point in their lifetime. It is estimated that 90% of people requiring Special Care Dentistry should be able to access treatment in a local, primary care setting. Provision of such primary care is only possible through the education and training of dentists. The literature suggests that it is vital for the dental team to develop the necessary skills and gain experience treating people with special needs in order to ensure access to the provision of oral health care. Education in Special Care Dentistry worldwide might be improved by the development of a recognised academic and clinical discipline and by providing international curricula guidelines based on the International Classification of Functioning, Disability and Health (ICF, WHO). This article aims to discuss the role and value of promoting and harmonising education in Special Care Dentistry as a means of reducing inequalities in oral health.
Health professionals, and the organisational systems upon which they depend, have a professional and moral obligation to all members of the community (1, 2). Unfortunately, immense inequalities still exist in relation to oral health, particularly amongst patients requiring special care (3–8). Lack of education has been cited as one of the barriers for the poor awareness of the importance of oral health for people with disabilities and, subsequently, one of the factors that impacts in the provision of oral health care for a significant number of individuals within society (1, 3, 4, 9–15). This article aims to discuss the role and value of promoting and harmonising education in Special Care Dentistry as a means of reducing inequalities in oral health.
Defining special care dentistry
One of the reasons that education in Special Care Dentistry has been traditionally neglected may be that the scope of the discipline is difficult to define. It has been suggested that use of the WHO International Classification of Functioning (ICF) may improve understanding and harmonisation in this domain (16, 17). The ICF provides a single classification and a common language for the description of functional ability in three dimensions: body function and structure, individual activity and participation in society (16). Disability is thus not considered an illness but is defined according to the individual’s human experience of functioning within their own environment (whether that person is able to fulfil his/her normal social role, regardless of the type of medical condition or disability). Using the ICF model, people requiring Special Care Dentistry have been defined as those with a disability or activity restriction that directly or indirectly affects their oral health, within the personal and environmental context of the individual (17). The advantages of this definition are that it takes into account the fact that not all people with disability require special care, and that people may require special care at certain times in their life but not others. Although the definition is very wide (including all possible medical groups, and including children, adults and older people), it is also very sensitive, as need is entirely dependent on the personal and environmental context. The population requiring special care may thus differ between countries and regions in relation to existing adult and child oral health service provision, cultural expectations and the provision of education in Special Care Dentistry to general dental practitioners and dental specialists. It is this definition of the population requiring Special Care Dentistry that is referred to throughout this article.
Prevalence of disability worldwide
Definitive worldwide data on prevalence of disability are lacking, and there is an urgent need for more robust, comparable and complete data collection. This process has been started by the World Health Survey, which derived its framework and functional domains from the ICF, and surveyed 70 countries, 59 of which were ultimately used to represent 64% of the world’s population (18). International data can thus be obtained from this survey and the Global Burden of Disease Survey (19) (Table 1). Based on 2010 population estimates (18, 19) and 2004 disability prevalence estimates (18), there are almost a billion adults estimated to be living with disability worldwide (15.6—19.4% of the population) (18, 19). This is higher than WHO estimates from the 1970s, which suggested a global prevalence of around 10% (20), and in the richer countries, the overall prevalence of disability is likely to keep rising with increasing age of the population (21, 22).
Table 1. Proportion of the world’s population living with disability
Evidence of inequality in oral health and reduced access to care for people requiring special care
There is worldwide recognition that people requiring special care have poor oral health and high levels of unmet need in terms of prevention, and in terms of periodontal, restorative and functional treatment. There are a multitude of studies to confirm this (4, 7, 23–49). Reduced access to preventive care has been demonstrated for people requiring special care in almost all areas of health, including dental care (24, 50–54). Particularly high levels of untreated dental disease have been demonstrated in those with behavioural problems, in those individuals living in institutional settings and when dependence was acquired later in life (25–27, 29, 55–57). Evidence shows that for many, the limited treatment available consists mainly of emergency extractions, often under general anaesthesia, rather than planned comprehensive restorative care (37, 58–61). However, there is a lack of high-quality, controlled studies, and this paucity of research needs to be addressed in the near future using the ICF to describe the influences on oral health in diverse populations (17, 62).
Multiple barriers exist to the access and utilisation of mainstream oral healthcare services by people with special needs, and these can be both patient- and dentist-centred (3, 21, 63, 64). The Convention on the Rights of People with Disability (CRPD) and the ICF highlight environmental factors such as attitudinal problems that restrict participation for people with disability and the need to widen access to improve health outcomes (16, 65). Anxiety has been shown to be a barrier to the utilisation of dental services by the general population, and this problem concerns up to a third of adults with intellectual disability (4, 23, 66, 67). Patient–doctor communication and practitioner attitudes have also been cited as limiting access to care for the general population (52, 68), and these difficulties are magnified when the patient has existing communication problems that the practitioner is untrained to deal with (69, 70). Awareness of architectural issues is also poor amongst practitioners – in one study, up to 77% of dental practices were considered by practitioners to be accessible to wheelchair users; however, only 7% also had suitable parking, access or toilet facilities (71). In the past, research has suggested that dentists have found this population stressful or too challenging to treat (11, 12, 22, 69, 71–74), and 76% of general dentists in one study reported finding it difficult to provide treatment for people with disabilities (71). Dentists may feel the pressures of time and that inadequacy of reimbursements creates disincentives to treat these populations (71, 75–77). Additionally, they may feel ill at ease when faced with human diversity or be concerned that they may have to reduce the technical quality of care for patients with reduced cooperation (69, 74, 78). The issue of ethical intervention is also important when the patient is unable to give informed consent, as the legal position in many countries is ambiguous (11, 75, 79) and highlights the need for interdisciplinary working. Practitioners may abstain from treatment if they feel that these issues have not been resolved (53, 80). Finding a dentist and receiving treatment have thus been shown to be difficult for people with special needs, but greatest for those with more severe disability (24, 25, 81, 82).
Current oral health service response to people requiring special care
It is evident globally that people requiring Special Care Dentistry find varied response from current health systems in relation to their specific needs. Service provision in most countries is by a general dental practitioner, often working benevolently with little or no compensation for extra time or resources spent. In some countries, practitioners may have the possibility to refer to general anaesthesia services; however, treatment may be limited to extractions (6, 37, 83). Some developed countries are exceptional in that service provision for this population is explicit, notably in Northern Europe and in Australasia. When specific special care services exist, staff is usually salaried (for example in a community, primary care or hospital service) and services are often oversubscribed. Specialised units in dental hospitals, clinics or faculties are rarely evenly distributed geographically. In some countries, specialist care is available as a public service, but in others, it is only available to those who can afford it. In others, paediatric special care is available to some but no clearly identifiable continuum of treatment exists into older years (84).
Education as a possible solution to improve access to oral health care
Reducing the social determinants of health inequalities, in particular social exclusion, requires action far beyond the scope of health services, but it does include the need for health services to be reorientated towards the promotion of health (85) and towards improved access to care. There is evidence that oral health services can improve quality of life and general health for special groups particularly by providing environmental facilitators to the reduction of disability following the ICF model. Primary health care has been defined as the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients and practising in the context of the family and the community (3). If the estimations made by the Joint Advisory Committee for Special Care Dentistry in the UK (JASCD) (86) and Gallagher & Fiske (22) are summarised, potentially 9 of 10 persons with special needs could be treated in the general dental service if problems of access were addressed. In order to attain this goal, dentists need to be educated and trained to develop the appropriate skills and knowledge to integrate their local community with special needs into their dental practice.
Dental practitioners cite lack of experience and insufficient undergraduate education and clinical exposure as reasons for being less likely to treat patients with disability (9, 71, 87, 88). The better practitioners rate their education in Special Care Dentistry, and the more experience they have, the more likely they are to treat this population once in practice (9, 10, 13, 88, 89). It appears that student, and ultimately dental practitioner, attitudes to diversity only improve through exposure (9, 11–15). It is therefore evident that students need much greater clinical experience of the treatment of children, adults and older people with special needs (90, 91). Based on similar evidence in the medical domain, education of students and professionals is specifically recommended in the recent WHO World Report on Disability (92) as a means of promoting health for this population. It has also been suggested that dental students’ attitudes improve when the social model of disability is favoured (93), such as that promoted by the ICF(16). Responsible education providers should also offer continuing dental education programmes for practising dentists and their teams, to improve both practical and communication skills when treating a person with a disability, and bringing their level of training in special care to that expected of graduating students.
In order to provide the necessary education and training for general practitioners and undergraduate and postgraduate students (94–96), experts in Special Care Dentistry are required. This implies the creation of an academic and clinical discipline within dental faculties to provide teaching, training and a career pathway (90, 94–97). The specific manner in which Special Care Dentistry is recognised in different countries will vary, however, depending on the existing organisation of dental teaching worldwide. Experts are also required to develop high-quality research into the specific problems and barriers experienced by people with disability in relation to oral health and to act as professional advocates for the oral health of this population. Dental representatives need to develop links with disability groups to drive public health policy, social integration and distribution of resources. This involves using knowledge of the evidence base to advocate for resources to improve education and training in oral health promotion and provision of appropriate services to limit social disability (1, 98).
Recognition of the discipline may also aid in the development of specialist services for the minority of patients with particularly complex needs who require care over and above that available in the primary sector, preferably integrated within multidisciplinary teams (3, 99, 100). Such services provide a valuable teaching environment and fulfil an important role in terms of service provision. The organisation of services will be different between countries and healthcare systems and may involve general practitioners with a special interest, qualified specialists as well as trainees (22, 101, 102). If the ICF definition of the population requiring special care is accepted, this should ensure that specialist services are only required for those unable to access or utilise mainstream care at a given point in time (16). The interface between primary and secondary services in specialist clinics or hospitals needs to be seamless and equitable with patients returning to the primary sector for follow-up and preventive care (103).
Current state of education in special care dentistry
There is little documentation regarding the existence or content of undergraduate teaching in Special Care Dentistry worldwide. In the UK, undergraduate curricula in Special Care Dentistry have been established within many adult departments incorporating a multidisciplinary approach (104). The Teacher’s Group of the British Society for Disability and Oral Health produced a framework document in 2004 that served as a template for British dental schools revising their curricula. The objectives centred on demonstrating positive attitudes towards diversity and included disability awareness, public health aspects of Special Care Dentistry and relevant ethics and legislation (105). The extent to which this framework has been applied has not yet been studied however.
In 2006, the American Dental Education Association (ADEA) adopted a resolution to ‘ensure that education programmes include both didactic instruction and clinical experiences involving treatment of people with special needs’ (106). The quantity, methods and content of teaching vary widely however between different dental faculties both within the USA and between the USA and Canada (107). In 70% of Canadian undergraduate programmes, curriculum related to patients with special needs is taught within the department of paediatric dentistry (108). In Brazil, at the undergraduate level, Special Care Dentistry is not included in most dental schools according to a report published in 2007 (109). In 2009, it was reported that Italian dental students spent about 4% of didactic and 5% of their clinical training in the dental care for patients with intellectually disability; however, most students (83%) rated this training as inadequate (110). Training in geriatric dentistry has also been reported as inadequate in Canada, India and Europe (111–114).
It is unknown whether formal undergraduate teaching in Special Care Dentistry exists in the countries not mentioned above, whether it is covered by other disciplines (notably paediatric dentistry) or whether there is simply a lack of available information. As Special Care Dentistry has only recently emerged as a recognised academic discipline in a few countries, it seems likely that Special Care Dentistry is not prioritised in the curriculum worldwide.
Postgraduate and specialist education
Currently, Special Care Dentistry is recognised as a registered specialty in four countries: Brazil, Australia, New Zealand and the UK. Within these countries, different educational programmes exist. In Australia, there is a doctorate programme for Special Care Dentistry and training pathways exist which lead to specialisation (115), whilst in New Zealand, postgraduate qualification as a specialist requires completion of the Doctor of Clinical Dentistry (Special Needs) training programme. A shorter diploma course is also available which allows the qualifying dentist to work on a ‘special interest’ basis. In the UK, specialist training programmes, a Masters degree and postgraduate diplomas are available. In Brazil, there were 11 specialist training programmes in 2007, although no additional Master’s or doctorate degree courses are offered (109).
Other countries teach Special Care Dentistry to postgraduate level; however, Special Care Dentistry is not yet recognised, or may only be in the process of being recognised, as a stand-alone specialty. These countries include the USA, Ireland, Japan, the Netherlands, Spain, Argentina and Mexico. In the USA, fellowship and diploma programmes in geriatric dentistry and dentistry for people with disabilities exist. Whereas in the past, the majority of training was completed through the field of paediatric dentistry (84), nowadays there are requirements for graduates of advanced general dentistry residency programmes to provide dental services for adults with special needs (116). In Ireland, postgraduate education and clinical training are provided at postgraduate diploma and doctorate levels. In Japan, training programmes are available which lead to certification by the Japanese Society for Disability and Oral Health (JSDH) and a doctorate programme is available.
Importantly, widely established postgraduate programmes in other specialties, such as oral surgery, paediatric dentistry and orthodontics, include certain teaching requirements regarding the care of people with disability. Notably, the European Erasmus Programme for the specialty education in orthodontics makes such provision (117) and highlights the need for interdisciplinary working and understanding within the specialities regarding the role of Special Care Dentistry.
Training of professionals complementary to dentistry
Special Care Dentistry is embedded in prequalification courses for dental nurses, hygienists and therapists in the Ireland, the UK and Argentina, whilst specific training pathways in special care for dental nurses have also been established in the UK (118). The Academy of Dentistry for People with Disabilities in the USA allows hygienists to take the fellowship examination and, if successful, to become fellows of the Academy. There is little evidence in the literature on the availability of specific training in other countries (119).
It would seem that international guidance is needed for the development of education in Special Care Dentistry, be it for undergraduates, postgraduates, continuing professional education or the extended dental team. The strongest example of global educational development was given at the Global Congress on Dental Education III in 2007, with 330 dental academics and educators from 66 countries meeting to discuss and launch a Global Network on Dental Education. The impetus grew from the DentEdEvolves Thematic Network Project which ‘recognised the value of collaboration, discussion and shared experiences’, and ‘the participants set out to identify common challenges, share experiences and promote the pooling of intellectual resources’ (120). Another example is given by the Association for Dental Education in Europe (ADEE), which published guidelines in 2009 regarding the competences required by dentists graduating within Europe. Special Care Dentistry does not appear as a specific item but is mentioned several times, particularly in relation to professionalism, communication, clinical information gathering, treatment planning and maintaining oral health (121).
The literature shows that people with disability worldwide are subject to flagrant inequality in oral health both in terms of prevalence of disease and unmet healthcare needs. In terms of provision of treatment, barriers to accessing quality primary dental care for this population must be removed. It is estimated that 90% of people requiring special care should be able to access treatment in a local, primary care setting (22), provided by a general practitioner, a practitioner with a special interest or dental care professionals such as therapists and hygienist where these roles exist (101). Implementation of primary care service provision is only possible through the education and training of dentists and the wider dental team together with the development of supportive legislation (9–15). The literature suggests that it is vital for the dental team to gain experience with and exposure to people with special needs in order to improve attitudes to human difference, and to ensure equality in the provision of oral health care for this population (9–15). The lack of education in Special Care Dentistry worldwide may be related to the lack of recognition of Special Care Dentistry as a clinical or academic discipline and to the lack of coherent guidelines as to curriculum contents.
With the development of the ICF, the World Report on Disability, the Convention on the Rights of Persons with Disability and the World Health Survey, it is now time for the dental profession to respond to the challenge of inequalities in oral health by promoting and harmonising education in Special Care Dentistry (16, 18, 65, 92), as a small step towards reducing inequalities in the provision of oral health care worldwide.
Any reader interested in education in Special Care Dentistry is invited to visit the International Association of Disability and Oral Health website (http://www.iadh.org) or contact the iADH Education Taskforce (SCiPE) at firstname.lastname@example.org.
The authors would gratefully like to acknowledge Professor June Nunn for her helpful comments during the writing of this article.