BY H. BARRY WALDMAN, DDS, MPH, PHD, STEVEN P. PERLMAN, DDS, MSCD, DHL (HON), FACD AND ALLEN WONG, DDS, EDD
The largest minority population in the United States without adequate dental care is individuals with disabilities.1 During the present decade, approximately 56.7 million residents (almost one-in-five members of the population) have some form of disability (including 39.9 million individuals with severe disabilities). Specifically, there are more than 3 million children through age 17 years with severe disabilities. (Note: the Census Bureau annual American Community Survey only reports data for hearing and vision difficulties for children less than five years of age.) There are many differences in the proportion and numbers of residents with disabilities by gender, race/Hispanic origins, age, and types of disabilities. There are greater proportions of persons with disabilities among:
• Females than males – to a degree, reflecting the greater numbers of women in senior years.
• American Indians & Alaska Natives, blacks and whites than Hispanics and Asians.
• Older than younger populations.
• Among individuals with ambulatory and cognitive disabilities than other disabilities
The projected estimated proportion and number of individuals with severe disabilities are not available for the year 2030. A projection of 45.8 million residents with severe disabilities was developed using Census Bureau general total national population and state projections for the year 2030.
In 2015 – The proportion of individuals with disabilities ranged from 9.9% in Utah and 10.3% in Colorado, to 19.4% in West Virginia and 21.4% in Puerto Rico.
The estimated number of individuals with severe disabilities ranged from 71,000 in Wyoming and 76,000 in the District of Columbia, to 3,126,000 in Texas and 4,097,000 in California.
In 2030 – Based on both the total number of state residents and proportion with disabilities for 2015, the estimated number of residents with severe disabilities will range from 65,000 in North Dakota and Wyoming, to 3,865,000 in Texas and 4,382,000 in California. 2,3
Access to dental care poses a challenge for children (and adults) with developmental and acquired disabilities because of the lack of adequate dental insurance and difficulty finding a dentist who is trained and willing to care for young children or adults with simple or complex medical conditions. One would assume in the final decades of the last century that dental schools throughout the country were providing educational experiences in the care of individuals with special healthcare needs in response to the deinstitutionalization and mainstreaming of the individuals. Regrettably, we would be wrong.
Persons with a wide range of disabilities are now living in our communities. We now see them in the movies, television programs, malls and in our communities. Nevertheless, the Commission on Dental Accreditation (CODA) had not established standards to ensure the inclusion of such educational programs for the care of individuals with special healthcare needs in dental schools.
Unfortunately, it was only through subterfuge that the Commission adopted a new standard for 2006 that educational programs in dental and dental hygiene schools in the U.S. were required to include some aspects of the preparation for the care of individuals with special needs. (See a report in a previous issue of EP Magazine for the details how this ruse was carried out.4)
Although many practitioners do provide care for children (and adults) with disabilities, the reality is that for those dentists who completed their dental education prior to the development of formal school programs, there are few if any continuing education courses for the care of individuals with special needs. 5
“The (health) service most commonly reported as needed but not received was preventive dental care; 6.3 percent of children with special health care needs over all needed but did not receive care preventive dental care.”6
And Children Become Adults
In the U.S. during the past year, 60% of adults with disabilities, and 70% of individuals with no disabilities reported a dental visit.7
Prevention: The Best Medicine for Oral Care
Good oral health, an important part of a person’s total health, starts in childhood. Every child can have healthy teeth and gums. Children with good strong teeth are able to chew a wide variety of foods for healthy nutrition. Healthy teeth aid speech development by helping children make proper sounds for speaking clearly. In addition, clean healthy looking teeth help individuals look better and feel better about themselves.8
“Children with special needs are a greater risk… With all the medical, nutritional, and emotional needs of children with disabilities, it is hard to find time for proper daily oral care. Getting the child to the dental office can be difficult, too. But preventing cavities and gum disease now is easier than correcting the problem later. Prevention can spare the child unnecessary pain and costly dental procedures.” 8
Alternative Care in Special Circumstances
The general recommendations for prevention of cavities and periodontal (gum) disease have been to brush your teeth twice a day with fluoride toothpaste, floss daily and visit your dentist twice a year. We now know that oral health must include treating the bacteria and chemistry of the mouth (the biofilm). Caries Management by Risk Assessment (CAMBRA) is a systematic approach that should be customized and initiated for every child or adult with special needs and might include probiotics (good bacteria that are either the same as or very similar to the bacteria that are already in our body), antimicrobials (an agent that kills microorganisms or stops their growth), baking soda, remineralizing agents, fluoride gels, varnishes rinses and sealants.
Conditions requiring additional considerations would include patients with intellectual and physical disabilities and those with dry mouth, reflux and swallowing difficulties. Caregivers are important and must be educated to ensure an effective hygiene program will be implemented and monitored. It is also important to realize that oral health care can be delivered anywhere if a bathroom is non-accessible.
Finding a Dentist
It may not be an easy task to find a dentist who is trained, willing and able to treat children and adults with special health care needs. Many studies have demonstrated the reality that the more significant the disabilities, the more difficult it is to find a dental professional who is willing to provide the needed care. In addition, limitations in insurance coverage, the restrictions of the Medicaid system (e.g. the elective inclusion of dental service coverage for youngsters as they reach their adult years) and general lack of funding for state programs, may provide additional barriers for care.
So What is a Minority Population?
The term “minority population” often is used of civil rights and collective rights which gained prominence in the 20th century. Members of minority groups are prone to different treatment in the countries and societies in which they live.
“…discrimination may be directly based on an individual’s perceived membership of a minority group, without consideration of that individual’s personal achievement. It may also occur indirectly by social structures that are not equally accessible to all. Activists campaigning on a range of issues may use the language of minority rights, including student rights, consumer rights, and animal rights.” 9
What about the rights of children with disabilities for needed oral health care?
ABOUT THE AUTHORS:
H. Barry Waldman, DDS, MPH, PhD is a SUNY Distinguished Teaching Professor , Department of General Dentistry, Stony Brook University, NY.
Steven P. Perlman, DDS, MScD, DHL (Hon), FACD is the Global Clinical Director, Special Olympics, Special Smiles and Clinical Professor of Pediatric Dentistry The Boston University Goldman School of Dental Medicine.
Allen Wong, DDS, EdD is Professor and Director AEGD Program, Director Hospital Dentistry Program, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, CA.
GROWTH & DEVELOPMENT CHECKLIST FOR PARENTS & CARE-GIVERS
- Try to prevent thumb-sucking, finger-sucking, or pacifier habits, which may cause future bite abnormalities, called malocclusion. Future orthodontic treatment may be difficult in individuals with severe disabilities or behavioral issues.
2. Keep an infant’s gums clean to help reduce teething discomfort. Use a gauze wipe or a washcloth moistened with water.
3. The American Academy of Pediatric Dentistry recommends an oral health consultation within six months of the eruption of the first tooth. This gives parents and care-givers an opportunity to become informed about dental care and preventing dental disease.
4. Be aware of “early childhood caries.” Do not put the child to bed for a nap or a night’s sleep with a bottle of sweetened liquid in his or her mouth (e.g., milk, formula, or fruit juices). When the child is sleeping, a decrease in salivary flow allows sugary liquids to remain in the child’s mouth for a long time, causing tooth decay. Breast feeding a child to sleep over along period of time can cause a similar problem.
5. Some liquid medications contain from 30% to 50% sucrose. These sugar-laden oral medications are most often given before nap time or bedtime, when salivary flow is diminished. Give the doses of medication when the child is awake, and have the child rinse thoroughly or drink water immediately after the dose. Be sure to inform the dental personnel of the medication the child is taking and the frequency and time of the dosages prescribed. If possible, request sugarfree medication from your pharmacist.
6. There is a wide range of timetables for eruption of primary and permanent teeth. Frequent dental care (at least semi-annually) can help to ensure proper guidance of developing teeth, and, if necessary, early interception of future malocclusions.
7. If the child’s primary (first) tooth has not fallen out, and the permanent tooth is erupting, seek care as soon as possible. Prompt removal of the over retained primary tooth can prevent orthodontic problems.
8. IF tooth crowding is present, an early orthodontic consultation is advisable. There are certain procedures that may be accomplished to limit or possibly avoid extensive orthodontic treatment.
– From Forewarned is Forearmed, by Perlman S, Fenton SJ, Friedman C, Chamalian D. EP Magazine, June 2001
- Dental schools provide training programs for all students to prepare them for the care of patients with special needs. In addition, dental school and hospital graduate residency programs for pediatric dentistry and general practice dentistry provide advanced training for the care of youngsters and adult patients with special needs.
- The American Academy of Pediatric Dentistry (www.aapd.org) provides a directory of all pediatric specialists who have received advanced training for the care of youngsters with special needs.
- The American Academy of Developmental Medicine and Dentistry (www. AADMD.org) has a national membership directory which includes a listing of trained dentists who provide care for individuals with special needs.
- Special Care Dentistry Association (www.scdaonline.org) has a national listing of dentists who provide care for individuals with special needs.
- Local dental societies maintain listings of practitioners who provide care for individuals with special health care needs.
- Some local hospitals maintain services for individuals with special needs on an in-patient and out-patient basis.
1. Waldman HB, Perlman SP. The largest minority population in the U.S. without adequate dental
care. Special Care in Dentistry, 37(4):159-163, 2017,
2. U. S. Census Bureau. 2015 American Community Survey 1 year estimates Available from:
http://factfinder.census.gov Accessed July 3, 2017
3. U.S. Census Bureau. Interim projections of the total population for the United States and States:
April 1, 2000 to July 1, 2030. Available from:
http://www.census.gov/population/projections/files/stateproj/SummaryTabA1.pdf Accessed July 5, 2017.
4. Waldman HB. I’m a liar and proud of it! Or, my introduction to reality. Exceptional Parent
5. Waldman HB, Wong A, Cannella D, Perlman SP. No one left behind. (Editorial) AGD Impact, (on
line) e-10-e12, July 2010.
6. U.S. Department of Health and Human Services. The National Survey of Children with Special
Health Care Needs Chartbook 2005-2006. Rockville, MD: Department HHS, 2007.
7. National Center on Birth Defects and Developmental Disabilities. Oral health and people with disabilities.
Available from: http://www.cdc.gov/ncbddd/documents/Oral%20Health%20Tip%20sheet%20_
PHPa_1pdf Accessed July 1, 2017.
8. Perlman S, Fenton SJ, Friedman C, Chamalian D. Forewarned is forearmed. EP Magazine,
9. Wikipedia. Minority group. Available from: https://en.wikipedia.org/wiki/Minority_group Accessed