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A peer-reviewed journal that offers evidence-based clinical information and continuing education for dentists.

Improving Access for Patients With Special Needs

A pilot program demonstrates how a new approach can improve care for these patients.

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Access to quality oral healthcare is a concern for many in the United States. In the past, initiatives such as the oral health coordinator were designed to facilitate dental treatment by going into the community and connecting underserved groups with accessible dental care.1 However, this initiative left out one of the most underserved groups: adolescent and adults with special needs. As adults with mentally and physically compromising conditions are living longer, their dental needs have grown proportionately. 

In an effort to provide comprehensive care for patients with special needs, it is important to have a skilled, knowledgeable dental team member who can listen, assess, and participate in care for this population. To address this need, a pilot program was established at the Henderson Dental Center at St. Joseph Mercy Oakland in Pontiac, Michigan, that involved a new position on the dental team — the dental prevention coordinator (DPC). A dental hygienist was the logical choice for this position, as this team member would meet the patient before treatment, participate in care, and follow-up after treatment — in whatever setting was required. 

Much like the oral health coordinator and visiting nurse model, the DPC would first meet the patient in the community setting. Patients residing in a group home (four to six people in a residence) were initially chosen, as these facilities are licensed by the state. After the DPC received training in state group home procedures, protocols and requirements, the local mental health agency began referring group home residents who were in need of dental care. 

FIGURE 1. The dental prevention coordinator reviews the patient’s medical records with the group home staff at the first visit to the group home.
FIGURE 1. The dental prevention coordinator reviews the patient’s medical records with the group home staff at the first visit to the group home.

DENTAL PREVENTION COORDINATOR IN THE COMMUNITY

After obtaining necessary consents, the DPC would visit the patient at the group home. This visit occurred at dinnertime for several important reasons. This would allow the DPC to view the social interactions of the patient, examine dietary preferences or restrictions, and observe eating and chewing. As all medical records were available at the home, there was ample opportunity to review complex medical records, and plan questions or medical consultations (Figure 1). Finally, after dinner, the DPC would observe dental hygiene practices in order to better understand the patient’s capabilities, toothbrushes and aides used, and degree of staff involvement (Figure 2). Meeting the home staff responsible for nighttime hygiene practices would be important to the success of dental treatment. 

DENTAL PREVENTION COORDINATOR IN THE OPERATING ROOM

The information gathered by the DPC is invaluable in scheduling the patient’s first visit for dental care in the clinic or a hospital setting. Due to personal familiarity, the DPC initially greets the patient at the facility. This is key because seeing someone who has actually been to the group home makes it much easier for patients with special needs to adjust. At this appointment, an examination is attempted and the clinical findings documented (as behavior will allow). Based on the home assessment by the DPC, as well as the observed needs and behavior, a decision is made by the dentist on where care will be delivered. For the cooperative patient, this may begin with periodontal treatment in the dental clinic, with no alteration in how care is delivered. For the patient with extensive needs and/or little cooperation, care may take place in the hospital operating room under general anesthesia.

When care will be delivered in the operating room, the DPC initiates the necessary consent forms and medical coordination to schedule the case. On the day of the procedure, the DPC serves on the clinical team treating the patient. Almost all of the patients treated have need for periodontal therapy, and the clinical hygiene skills of the DPC make this individual a valuable member of the team. This is also an opportunity for the DPC to view all areas of the oral cavity, and with excellent radiographic support, so as to gain a thorough understanding of the patient’s oral condition. Once the periodontal treatment is completed, the dentist and dental residents perform the restorative and surgical procedures deemed necessary. 

FIGURE 2. The dental prevention coordinator observes self-care hygiene practices on the visit to the group home. This allows for a realistic assessment of home care before treatment begins.
FIGURE 2. The dental prevention coordinator observes self-care hygiene practices on the visit to the group home. This allows for a realistic assessment of home care before treatment begins.

DENTAL PREVENTION COORDINATOR AS AN EDUCATOR

Following completion of periodontal treatment, the DPC can leave the operating room and meet the caregivers who are assigned to the patient. After reassuring them of the safety and progress of the case, the DPC can begin the educational process. In addition, the DPC can review precautions and restrictions following general anesthesia and dental treatment. Once all of the calculus and plaque are removed, hopeless teeth extracted, and the teeth restored, it is a new start for the patient. Most importantly, the DPC and other team members can advocate for regular home hygiene to improve and maintain the new level of oral health following initial care. Having visited the group home and observing the patient’s oral hygiene practices, the DPC can realistically suggest techniques and routines to support improved oral health. 

This level of support continues with a home visit two to three days after the procedure. At this time, the DPC can answer questions about recovery from general anesthesia and begin to support home hygiene efforts with the group home staff. All too often, unfortunately, the staff does not want to “hurt” or “disturb” anything — and this is usually not the right approach. Again, this presents an opportunity for the DPC to provide caregiver education. These steps are key, because the immediate period following definitive treatment is the time to clean healing tissues and implement postoperative instructions given at the hospital or clinic. The DPC is present to review these instructions and coach the staff on necessary home care. When the patient is seen back in the hospital or clinic two to three weeks after the procedure, the continuity of the DPC once again plays a significant role in coordinating the group effort to help the patient attain optimal oral health. 

There are many benefits to having a skilled dental hygienist in the role of DPC. As with any type of community outreach, it first requires someone who is comfortable meeting new people. As many of the patients have complex medical histories, the DPC must determine the relevant facts on history, medical status and medications. Frequently, the primary care physician may not have a thorough understanding of the oral health needs of the patient, or the dental implications of prescribed therapies. 

Due to the in-depth, coordinated approach led by the DPC, medical management is sometimes adjusted and improved by the dental team’s involvement. This can prove beneficial in preventing complications in cases involving oral care under general anesthesia. Additionally, this approach can yield improved systemic health. Just as dental care is often an unmet need among this population, these patients may have unmet medical needs, as well. For example, while reviewing the medical history, the DPC might find that a PAP smear and pelvic exam are warranted for female patients. Coordinating testing and other treatment at the same time dental care is delivered leads to more comprehensive care in a safe and cost-effective manner. 

Quite often, patients who are nonverbal cannot communicate the oral pain they may be experiencing. The pain may result in behaviors that are not typical, yet medical providers and caregivers do not consider a dental etiology for the behavior. In the past, delayed diagnosis of dental problems has led to emergency extraction of teeth, and further oral health issues. Here again, the DPC’s relationship with caregivers in the group home helps provide support and education for the home staff — and, ultimately, true preventive and maintenance care for the patient. 

Based on our experience with the DPC model at St. Joseph Mercy Oakland, once a patient’s acute dental problems are resolved, it often becomes easier to perform periodontal maintenance procedures in the clinic, with no special accommodations. This can result in a more comfortable, maintainable level of oral health that can be supported in the future. Thus, having a dental team member who is focused on treatment and prevention helps support the oral and systemic health of this patient population.

As this pilot program demonstrates, utilizing the training of a dental hygienist allows for expansive opportunities to help educate and make the community aware of the oral healthcare needs of these patients. Whether it involved answering questions regarding adults with special needs, or being a resource to the county mental health agency, the dental knowledge of the DPC proved essential. 

SUMMARY 

Educating dental and dental hygiene organizations through meetings, clinics, and articles like this helps everyone in the profession reassess how we can improve treatment for those with special needs. 

Assessment of the DPC pilot program demonstrates this new team member can facilitate respectful, comprehensive care in the least restrictive setting. Where a patient with special needs may have been uncooperative to begin with, an ongoing relationship with a skilled provider can allow for a better dental experience. Ultimately, the continuity and coordination of care provided by a DPC seeing patients in a group home supports greater cooperation, more frequent visits, and improved oral and systemic health for this population. 

Acknowledgment: The authors thank and acknowledge Stephanie Demoss, RDH, BS, the first dental prevention coordinator, and the support of the Jewish Fund of Metropolitan Detroit.

REFERENCE

  1. American Dental Education Association. Temple University to Serve as Site for New ADA Pilot Program to Help Serve Area Communities. Available at: http/://www.adea.org/ADEA/Blogs/Bullet_n_of_Dental_Education/Temple_University_to_Serve_as_Site_for_New_ADA_Pilot_Program_to_Help_Serve_Area_Communities.html. Accessed February 8, 2022.

From Decisions in Dentistry. March 2022;8(3)20-21.

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