Why Is Providing Dental Care to People with Mental Retardation and Other Developmental Disabilities Such a Low Priority?

Transcription

1 Viewpoint Why Is Providing Dentl Cre to People with Mentl Retrdtion nd Other Developmentl Disbilities Such Low Priority? H. Brry Wldmn, DDS, MPH, PhD Steven P. Perlmn, DDS, MScD b [I]n course of study in dentl cre for hndicpped children ws reltively new to the dentl school curriculum.... [I]t ws not considered n essentil prt of the dentl school curriculum even s recently s the erly 1970s In the pst, individuls with severe disbilities were often neglected by the dentl profession becuse of: () lck of bsic knowledge regrding the ptient nd pproprite physicl nd/or psychologicl mngement, (b) lck of experience, (c) ssumed disruption of the office routine, (d) presumed need for specil fcilities nd equipment, nd (e) indequte compenstion for incresed time involvement in tretment. 2 But fter 50 yers of experience, why is dentl cre for people with mentl retrdtion nd other developmentl disbilities (MR/DD) such continuing low priority? Mybe becuse these concerns continue, but with dded significnce. Only fter ll is sid nd done with the nondisbled community do people with disbilities get ny ttention. 3 A LACK OF BASIC KNOWLEDGE Repeted studies hve shown tht dentl school grdutes do not gin the necessry expertise to tret ptients with MR/DD. The results of ntionl study of U.S. nd Cndin dentl schools crried out t the end of the 1990s, with informtion supplied by fculty/dministrtion, 4 showed ctul decreses in the lloction of time for the trining of students in the cre of services for individuls with MR/DD over the four yers of eduction: More thn hlf of the schools provided less thn five hours of didctic trining. 4,5 Almost three-qurters of the schools provided 5% or less of clinic time for cre of ptients with MR/DD. 4,5 The results of regionl 2001 study of third- nd fourth-yer dentl students ttitudes, beliefs, nd trining experience relted to individuls with mentl retrdtion mirrored the findings of the previous studies: Deprtment of Generl Dentistry, School of Dentl Medicine, Stte University of New York t Stony Brook, Stony Brook, NY b Specil Olympics, Specil Smiles, Lynn, MA; Deprtment of Peditric Dentistry, Boston University Goldmn School of Dentl Medicine, Boston, MA Address correspondence to: H. Brry Wldmn, DDS, MPH, PhD, Dept. of Generl Dentistry, School of Dentl Medicine, SUNY Stony Brook, Stony Brook, NY 11794; tel ; fx ; e-mil <hwldmn@notes.cc.sunysb.edu> Assocition of Schools of Public Helth 435

2 436 Viewpoint Almost two-thirds (63%) of students reported tht they hd never treted n individul with mentl retrdtion. 6 82% of students reported less thn five hours of didctic time devoted to treting individuls with mentl retrdtion. 6 A ntionl study of dentl hygiene progrms reported comprble findings: 48% of 170 progrms hd 10 hours or less of didctic trining (including 14% with five hours or less). 7 57% of progrms reported no clinic experience. 7 The indequcies in the preprtion of dentl school nd dentl hygiene school grdutes hve been demonstrted repetedly during the didctic nd clinic trining progrms tht the Specil Smiles component of Specil Olympics hs crried out throughout the United Sttes for more thn eight yers (Unpublished dt, Specil Olympics, 2001). THE PLAYING FIELD HAS CHANGED As result of developments since the mid-1950s in the cre of individuls with MR/DD (including the development of psychoctive drugs, deinstitutionliztion, minstreming, nd inclusion ) hve incresed this popultion s dependency for dentl (nd other helth services) on community prctitioners. 8 In the 30-yer period through the end of the 1990s, the number of institutionlized residents with MR/ DD decresed by 75%. 9 The number of residents with MR/DD residing in psychitric institutions decresed by 91%. 9 Specificlly, in the mid-1960s, there were more thn qurter of million individuls with MR/ DD in stte institutions. 9 By the lte 1990s, there were fewer thn 58,000 residents with MR/DD in stte fcilities. 9 In ddition, untold thousnds of youngsters nd dults hve remined with their fmilies s stte institutions hve been shut down. In the pst, lrge stte institutions (to some degree) offered wide rnge of in-house helth services provided by medicl nd dentl stff. Almost ll of the current community residentil fcilities, however, re too smll in size to provide in-house services beyond the nnul exmintions tht re required in some sttes. As consequence, the monitoring nd delivery of helth cre cn be difficult when services nd helth records re divided mong multiple providers nd loctions. Although no ntionl studies provide generl view of the dentl needs of people with MR/DD, locl studies, including one of Independent Living Centers in Msschusetts indicte prticulr needs for services People with disbilities experience the sme generl dentl helth problems s people who re not disbled, but for mny of the former, these conditions serve s dded impediments. Nevertheless, while there is incresed wreness of the need to improve ccess to qulity medicl services [for individuls with disbilities], dentistry hs lrgely been ignored. 13 DENTAL STUDENT AND PRACTITIONER CIRCUMSTANCES HAVE CHANGED Decresed numbers of dentl students, mrked increses in student debt, chnges in prctitioner-topopultion rtios, third prty economics, nd relted developments re contributing fctors to the low priority given to the dentl cre of individuls with MR/DD. Number of dentl students During the pst 30 yers, there hve been wide swings in the numbers of pplicnts to, nd first-yer plces in, schools of dentistry. From 1970 to 1975, there ws 77% increse in the number of pplicnts (from 8,878 to 15,734 pplicnts), followed by two-thirds decrese to pproximtely 5,100 pplicnts in 1990, nd in turn, by n increse to 9,000 pplicnts in 1999 (Tble 1) The number of first-yer plces in dentl schools mirrored these wide swings, with first n increse, followed by one-third decrese nd more recent slight increse. (There were times in the lte 1980s when the number of pplicnts lmost pproximted the number of entering plces.) The lrgest number of first-yer plces ws in 1978 (6,301), the smllest pplicnt-to-entering plce rtio since 1950 ws in 1988 (1.26), nd the smllest number of entering plces since 1966 ws in 1989 (3,979). Tble 1. Applicnts nd first-yer enrollees in U.S. dentl schools: selected yers, Rtio of Number of Number of pplicnts Yer pplicnts enrollees to enrollees ,878 4, ,734 5, ,601 6, ,216 4, ,123 4, ,437 4, ,010 4, SOURCES OF DATA: References

3 Dentl Cre for People with Developmentl Disbilities Low Priority 437 Tble 2. U.S. popultion nd number of privte dentl prctitioners: selected yers, , nd future projections U.S. resident Number of ctive privte Number of ctive privte Yer popultion (millions) dentl prctitioners prctitioners per 100,000 popultion , , , , , , , , SOURCE: Reference 14. Preliminry estimtes. Number of dentl prctitioners The overll result of the roller-coster ride during the pst three decdes in the number of dentl students ws 50% increse in the number of ctive privte prctitioners, nd until 1997, increses in the prctitioner-to-popultion rtio (Tble 2). 14 As result of the continuing increse in the generl popultion nd one-third decrese in the number of dentl school entering plces, progressive decline in the prctitioner-to-popultion rtio during the next 20 yers is projected (Tble 2). In terms of the incresing prctitioner-to-popultion rtios through the lte 1990s, one might ssume tht prctitioners would be eger to increse their prospective pool of ptients even ptients with MR/ DD. But other fctors re involved. Student debt nd employment From the erly 1980s to the lte 1990s, the men debt of grduting dentl students more thn tripled, reching $84,000 in 1998 (n increse of 87% in terms of constnt dollrs i.e., with the effects of infltion removed) (Tble 3). 14 The nnul tuition in some dentl schools is more thn $40,000. The men debt of dentl students who hd debts in 2000 ws $106, This ws 13% lrger thn the men debt of medicl students with debts ($94,000). Incresed numbers of dentl school grdutes hve sought employment nd/or postdoctorl eduction in dvnced generl dentistry progrms in n effort to py off mounting debts. 17 The employment of incresed numbers of dentl uxiliries together with greter numbers of new dentl school grdutes hve drmticlly chnged the verge dentl estblishment In 1980, 69.1% of den- tl fcilities hd fewer thn five employees. 18 (Employees my include dentists, dentl hygienists, dentl ssistnts, office stff, etc.) By 1999, despite n increse of lmost 30,000 estblishments, there ws decrese by more thn 6,000 of these smller dentl estblishments. 20 By the end of the 1990s, 45.9% of dentl estblishments hd fewer thn five employees 20 (Tble 4). Should recent dentl grdutes (nd dentl hygienist grdutes) join ongoing lrger prctices s employees or junior prtners, they my hve limited opportunities to lter estblished priorities in ptient selection. Thus, they still my not gin sufficient experience in the cre of ptients with specil needs since most privte prctices exclude these ptients from their ptient pools. (The relity for this exclusion is tht dentists who re willing to tret individuls with disbilities re often inundted with referrls from collegues who re not so inclined. 4 ) Tble 3. Grduting dentl student debt: selected yers, Men debt in current Men debt in constnt Yer dollrs (thousnds) dollrs (thousnds) SOURCE OF DATA: Reference 14. Constnt dollr bse = 1998.

4 438 Viewpoint Tble 4. Distribution of dentl estblishments by number of employees: 1980, 1990, 1999 THIRD PARTY ECONOMICS Percent of estblishments Number of employees SOURCES OF DATA: References [O]verhed ptient cre run(s) between 60 70% of the dentl fees nd cost of just under $10.00 per office visit for regultory complince, primrily including mndted infection control nd OSHA regultory complince. 21 In 1999, the Dentl Society of the Stte of New York, privte dentists, nd prents brought n ction in U.S. District Court ginst the governor, the Acting Commissioner of Helth, nd the Director of the Division of the Budget. The complint lleged tht: [The] indequte Medicid fee schedule discourges dentists from prticipting in the progrm nd frustrtes the mndte of the Medicid lw New York s dentl fees represent reimbursement rtes of between 10 nd 30% of the usul nd customry fees estblished by privte insurnce crriers for their New York City insured [enrollees] Ntionlly, constnt dollr per-ptient Medicid dentl expenditures hve continued to decrese since the mid 1970s In 1998, Medicid constnt dollr expenditures per ptient were less thn hlf of the rte in 1975 (Tble 5). In ddition, since the mid-1980s, expenditures for dentistry hve represented decresing shre of ll Medicid helth spending. 26 Now dd these relities: Medicid serves s primry source of funding for dentl services for significnt proportion of youngsters with MR/DD. 27 Medicid dentl cre is mndted for eligible children under the Erly Periodic Screening, Dignostic nd Tretment Progrm. But, only bout one in five Medicid-eligible children receive ny preventive dentl services by ge Medicid dentl cre for dults is n elective service. In mny sttes, Medicid dentistry is limited to emergency cre usully limited to extrctions. 28 As result, Children with disbilities re ging out of dentl cre. 29 Administrtive nd pperwork frustrtions s well s prticulrly high incidence of ppointment noshows only dd to the frustrtion nd limited prctitioner prticiption in the Medicid dentl progrm. 28 But most significnt is the long-term limited government support for ll spects of dentl cre. For exmple, in 1999, combined federl, stte, nd locl government spending for ll dentl cre represented 4.6% of ntionl dentl expenditures, compred to 32.3% of physicin expenditures nd 59.5% of hospitl cre spending. 25 And these economic shortcomings do not tke into considertion the often dded time nd expenses ssocited with the dentl cre of individuls with MR/DD! Tble 5. Expenditures for Medicid dentl ptients: selected yers, Expenditures for Number of Expenditure Expenditure per dentl cre in ptients per ptient ptient in Yer dollrs (millions) (thousnds) in current dollrs Dentl CPI constnt dollrs , , , , ,019 6, , SOURCES OF DATA: References Dentl component of the Consumer Price Index, bsed on: = 100.

5 Dentl Cre for People with Developmentl Disbilities Low Priority 439 REALITIES AND CHALLENGE Among the 53 million dults with disbilities in the United Sttes in 1997, 33 million hd severe disbility nd 10 million needed ssistnce in their dily lives [including millions with MR/DD]. 30 Given the relities of incresed numbers of individuls with MR/DD living in locl communities dependent for cre on locl dentl prctitioners, projected decreses in the privte dentl prctitioner-to-popultion rtios, limited dentl nd dentl hygiene school trining opportunities, incresing dentl grdute debts, chnged prctice rrngements with incresing number of employed dentists in estblished prctices, nd limited third prty reimbursements, prticulrly by government gencies, is there ny reson to believe tht there will be ny chnge in the certinty tht providing dentl cre for individuls with MR/DD will continue to be low priority? REFERENCES 1. Cstldi CR. Preprtion of the undergrdute student to render cre for the hndicpped child. J Dent Educ 1957;22: Mink JR. Dentl cre for the hndicpped child: elective course. J Dent Child 1971;28: Hunt DC, Growick BS. Mnged cre for people with disbilities. J Rehb 1977;63(3): Fenton SJ. People with disbilities need more thn lip service [editoril]. Specil Cre Dent 1999;19: Romer M, Dougherty N, Amores-Lfleur E. Predoctorl eduction in specil cre dentistry: pving the wy to better ccess? J Dent Child 1999;66: Wolff A, Milno M, Perlmn SP. Dentl student ttitudes nd experience towrds individuls with mentl retrdtion [bstrct]. Peditr Dent 2002;24: Goodwin M, Hnlon L, Perlmn SP. Dentl hygiene curriculum study on cre of developmentlly disbled. Boston: Forsyth Dentl Center; Wldmn HB, Swerdloff M, Perlmn SP. Children with mentl retrdtion: stigm nd stereotype imges re hrd to chnge. J Dent Child 1999;66: Anderson LL, Lkin C, Mngn TW, Prouty RW. Stte institutions: thirty yers of depopultion nd closure. Ment Retrd 1998;36: Cumell S, Rnsford N, Lyons J, Burnhm H. Needs for orl cre mong people with intellectul disbility not in contct with Community Dentl Services. J Intellect Disbil Res 2000;44(Pt 1): Gbre P, Ghnberg L. Dentl helth sttus of mentlly retrded dults with vrious living rrngements. Spec Cre Dentist 1994;14: Arnett H. First round results of the Access to Helth Survey: selected disbilities nd secondry conditions. Boston: Independent Living Centers; Dougherty N, Romer M, Birenbum A. Protecting dentl service for people with developmentl disbilities. N Y Stte Dent J 1997;63(6): Helth Policy Resource Center. Future of dentistry. Chicgo: Americn Dentl Assocition; Den s briefing book: cdemic yer. Wshington: Americn Assocition of Dentl Schools; Americn Dentl Eduction Assocition. Applicnt nlysis: 1999 entering clss. Wshington: Americn Dentl Eduction Assocition; Vlchovic RW, Wever RG, Sinkford JC, Hden NK. Trends in dentistry nd dentl eduction. J Dent Educ 2001;65: Deprtment of Commerce (US), Bureu of the Census county business ptterns. Wshington: Government Printing Office; Deprtment of Commerce (US), Bureu of the Census county business ptterns. Wshington: Government Printing Office; Deprtment of Commerce (US), Bureu of the Census county business ptterns. Wshington: Government Printing Office; Dentl Society of the Stte of New York et l. v. George E. Ptki, Governor of the Stte of New York. United Sttes District Court, Northern District of New York, 99- CV0156, Februry 2, Helth Cre Finncing Administrtion (US). Medicre nd Medicid sttisticl supplement, Helth Cre Finncing Review Annul Supplement. Bltimore (MD): Helth Cre Finncing Administrtion; Pub. No Socil Security Administrtion (US). Socil Security nnul supplement, Wshington: Government Printing Office; Census Bureu (US). Sttisticl bstrct of the United Sttes, Wshington: Government Printing Office; Cown CA, Lzenby HC, Mrtin AB, McDonnell PA, Sensenig AL, Smith CE, et l. Ntionl helth expenditures, Helth Cre Finnc Rev 2001;22: Wldmn HB, Swerdloff M. New York Stte Medicid dentistry in the 1990s: mtter before the courts. N Y Stte Dent J 1999;65(7): Brown JG. Children s dentl services under Medicid: ccess nd utiliztion. Sn Frncisco: Deprtment of Helth nd Humn Services (US), Office of the Inspector Generl; 1996 Apr. Report No. OEI Council on Dentl Cre Progrms survey results nd fct sheet of stte dentl progrms in Medicid. Chicgo: Americn Dentl Assocition; undted. 29. Wldmn HB, Perlmn SP. Children with disbilities re ging out of dentl cre. J Dent Child 1997;64: Census Bureu (US). Popultion profile of the United Sttes: Americ t the close of the 20th century. Current Popultion Reports P Wshington: Government Printing Office; 2001.