The April JADA editorial, "Back to the Future," was right on the mark, especially as it relates to the dental care of disabled persons. Improving access to routine dental services for this population does require more than raising Medicaid fees. This is evidenced by the recently filed class action suit in Pennsylvania against the Department of Public Welfare, or DPW, for failure to provide the needed dental services for people with disabilities.
In May 1999, the DPW held a joint conference sponsored by the Pennsylvania Dental Association relating to Medicaid and dentistry. The major issues were dental care for children and the disabled. Shortly after this conference, the fee schedule for children was increased to a very workable level, with payments even higher than some contracted preferred provider plans. Nothing was changed regarding the status of the disabled, especially for those over age 21. Limited periodontal therapy was just introduced for all adult Medicaid patients.
In Pennsylvania, the disabled patient on Medicaid is in the same category for dental care as all adults on Medicaid. There is only limited coverage for periodontal services, usually the major dental disease of disabled persons. They are only allowed one preventive prophylaxis visit per year, when sometimes professional cleaning every three months would control the periodontal problems.
There are restrictions on placing certain types of restorations that would improve function and quality of life for these disabled persons. An interesting dichotomy is that the Pennsylvania Department of Health has regulations for disabled people in institutions (private, state and group living facilities) to have at least two preventive dental visits per year, while DPW, which covers the fees for this service, allows only one visit.
Inadequate fees for the needed time and staffing to provide the appropriate care for this population is only one issue. The major matter is finding dentists and hygienists willing to provide the care. In the 1960s and 1970s, dental schools were providing both didactic and clinical courses for undergraduates (dentists and hygienists) in caring for special patients.
Now only a handful of schools have such programs (notably the University of Washington and the State University of New York at Stony Brook). Many schools answer surveys of the Academy of Dentistry for Persons with Disabilities indicating that they have clinics for special-needs patients. But when more data are requested, it [turns out to be] a clinic to treat infectious-disease patients and does not cater to people with other physical or mental disabilities.
The major problem is that students are not being exposed to the care of persons with disabilities in their undergraduate and postgraduate education. This is a very challenging aspect of practice and just as satisfying to accomplish as seating a roundhouse prosthesis.
Most of special-needs dentistry seems to be relegated to pediatric dentistry because of a behavior component. In most areas the pediatric dentists take good care of the under-21 population with special needs. This is part of their training. Who is being trained to take care of the adult patient with special needs—with mobility problems, mental retardation and cerebral palsy as well as those who have had strokes and the many other unfortunate individuals who need some type of special approach to their dental needs?
Not only are they being denied access to care because trained and willing dentists and hygienists are unavailable in their community, but those who are willing to provide this care cannot be compensated at an adequate level by government and social agencies to cover the costs of increased time and staffing needed to serve this population.
The caregivers responsible for these patients are not being given the appropriate training in preventive dentistry techniques necessary to improve the patient’s quality of life. This inadequate daily care makes the problems worse for these patients. Our profession has made very little [progress] in requiring and teaching the caregiver these important daily hygiene practices.
We must be proactive in providing for the dental needs of persons with disabilities. Our dental educational institutions (dental schools, hygiene programs, residencies and continuing education courses) must implement both didactic and clinical programs as soon as possible. The American Dental Education Association, in conjunction with the Academy of Dentistry for Persons with Disabilities and Special Care Dentistry, should develop curriculum guidelines for these programs.
The issue of access to care for disabled individuals is an important one for us as dentists. The dental profession must be an advocate for the oral health of persons with disabilities. We must begin working with state and federal agencies, advocacy groups and other organizations involved with helping the disabled. If we do not take a major step toward improving access to care, we will soon be forced to do this on someone else’s terms.
