A positive way forward
Dental health for all: Critical steps for reducing inequalities in oral health for people with disabilities
In 2012, the International Association for Disability & Oral Health (iADH) took a big leap forward in addressing the oral health inequalities faced by people with disabilities by launching guidance for designing an undergraduate curriculum in special care dentistry.
Ten years on, we have seen plenty of progress in the attitudes towards better treatment for this diverse population of patients, but there is still a long way to go. The experience students gain in special care dentistry during undergraduate training continues to be incredibly ad hoc. Even today, it is still very possible for a student to graduate from dental training without having treated one person with a disability.
People with disabilities have problems accessing care wherever they live in the world. When they do receive treatment, the outcomes often fail to meet the standards seen for the general population. So, where do we go from here? How do we ensure that people living with disabilities have access to quality oral health care and outcomes?
Approximately one in five people are living with a disability.1 Training needs to reflect the world we live in so that students are able to provide care for their whole community following graduation and are equipped with the skills and confidence to do so.
To truly improve outcomes for people with disabilities, we need to elevate the importance of special care dentistry within both clinical practice and dental team training. Exposure to people with disabilities should be seen as an essential part of professional training, not just ìnice to haveî. This means mandatory inclusion of special care dentistry in all undergraduate programmes, with structured training and assessments, including logbooks showing diverse patients during clinical training ñ the same as any other dental discipline.
This isn’t the case currently. In the United Kingdom and Ireland, we see vastly different scenarios between institutions, ranging from ad hoc exposure to exemplary programmes that include special care dentistry as a clinical speciality with associated academic departments. In some dental hospitals, exposure depends entirely on whether a person with a disability visits the hospital for treatment ñ and even then, there is no guarantee that there is a trained expert on hand that can guide the student on how to provide quality care to that individual. This type of scenario just wouldn’t happen in endodontics or oral surgery training.
Many students will have had no exposure to people with disabilities growing up, so it can be very daunting to work with someone with special healthcare needs. When it comes to special care dentistry, itís necessary for students to learn how to make reasonable adjustments to their typical approach. Itís all about learning to problem-solve, work together, make adjustments and find a path forward for each individual patient that truly demonstrates a studentís understanding of patient-centred care.
Training needs to promote an inclusive model of disability that recognises that no two patients are the same, even if they share the same diagnosis. It should also embrace the International Classification of Functioning, Disability and Health (ICF) – recognising that we are all on a spectrum of ability and disability. Students should spend time with people with disabilities in non-dental environments, through community projects, to encourage them to question their pre-existing beliefs. As students start to become familiar with different types of diversity, they can start to focus on providing personalised, precision care for everybody.
It’s also important for students to have time for reflection. What did they learn? What did they find easier or harder than expected? Where may unconscious bias be setting in? It’s all a learning curve and students should be given the chance to build confidence over time, rather than being thrown in at the deep end. They can start with prevention and communication, then work up to doing simple treatments within their clinical competency.
A change in mindset
Dentists often think that people with disabilities can’t achieve good oral hygiene, which is not the case at all. It’s just that they need the right equipment, the right level of assistance, and creative and innovative solutions.
A big part of educating students and dental professionals about working with people with disabilities involves getting them to rethink their assumptions and question unconscious bias. Providing quality care to people with
disabilities isn’t solely about getting them through the door, it means ensuring that treatment outcomes are equitable as well.
Longitudinal ageing studies show that people with disabilities struggle to access preventative care, as well as periodontal, restorative and functional treatment.2
One study in Ireland found that the more often people with intellectual disabilities visited the dentist, the fewer teeth they had ñ due to the increased likelihood of undergoing extractions compared to able-bodied peers.3
Equitable care requires a mindset shift, with dentists thinking about how to facilitate the right care for each person. Finding strategies to restore rather than extract teeth to maintain function should be easier nowadays due to technological advances such as rotary endodontics. For patients with physical disabilities, a whole range of aids are available to assist with brushing and maintaining good oral hygiene. Disability does not equal poor oral health, yet this has been written into textbooks over the years – so it will take time to change the mindset and attitudes of trainers and students alike.
Mainstream acceptance and support
Just like sustainability, special care dentistry should be embedded into the whole curriculum, not taught in a silo or added as an afterthought. For example, if students are studying communication, they should be taught how to communicate with people with hearing impairments or aphasia as part of that module. If they are learning about consent, they should learn how to assure autonomy for those with disabilities as well as assisted decision-making processes for individuals without the capacity to make their own decisions. The skills students learn from working with diverse patients are transferable skills for the whole population. Communication, teamwork, planning, problem-solving, patient centricity ñ these skills are at the heart of quality care and are valuable for treating all patients with dignity.
This also needs to carry through to general practice. While some people with disabilities require specialist care at designated clinics with highly trained teams, 85% of people with disabilities can and should be treated within general practice.4 We have seen amazing technological advancements that can make care so much better for all kinds of patients. Think about how much easier treatment has become with digital solutions like CAD/CAM compared to traditional impressions. We have the tools available to make life easier for patients and scales to measure the complexity and skills needed to take on a certain case.
Just as we need specialist oral surgeons to take on difficult wisdom teeth removals, there is always going to be a subset of patients with disabilities that require specialist care. Thatís where postgraduate education comes into play. But, in the end, itís not about whether someone is a specialist or not. Itís about whether they have the skills, training and equipment to treat someone ñ plus the willingness to do so.
Looking to the future
There is still a lot of work to be done to address the oral health inequality experienced by people with disabilities, but we know the steps we need to take on the path ahead. This year, the World Health Organization adopted a landmark global strategy on oral health, setting a bold but essential vision for universal oral health coverage by 2030. It’s a significant step in the right direction, but it will take time. Change also needs to be built from the ground up, by training the next generation of dental professionals.
My dream is for special care dentistry to be seen as something that is cutting edge and allows diverse individuals to achieve their personal best health, not a sub-standard compromise. Something that is included in every dentistry conference, the focus of long-term research, and driven by specialist postgraduate training.
A discipline that showcases precision care at its finest and is inclusive of all members of our community.
Because good oral health isn’t a luxury, it’s a human right.
This article was based on a presentation by Professor Alison Dougall for the digital event ‘Special Care Dentistry: Reducing Inequalities – Bridging the Gap’, organised by Dentsply Sirona International Special Clinic Solutions on 15 November 2022. Dentsply Sirona is committed to supporting clinicians to go beyond and help build a dental industry that is fairer, more inclusive and ensures the highest standards of ethics and responsibility. For a recording of this training event, contact firstname.lastname@example.org. Professor Alison Dougall is Head of Child and Dental Public Health at Trinity College Dublin and Director of the Doctorate Training Programme in Social Care Dentistry. She is the past president of the International Association for Disability & Oral Health (iADH) and led the International Task Force that produced consensus guidelines for developing a curriculum on special care dentistry. She was the Health Leader in Ireland in 2018 and 2021 won the John Tomes Medal for the international impact of her body of work. Professor Dougall is a clinical consultant providing comprehensive care for people with complex healthcare needs. In addition to writing a clinical guide to special care dentistry, she has more than 45 articles published in peer-reviewed journals.
¹ World Health Organization (2022), Disability Factsheet. https://www.who.int/news-room/fact-sheets/detail/disability-and-health.
² Faulks, D., Freedman, L., Thompson, S., Sagheri, D. and Dougall, A. (2012), The value of education in special care dentistry as a means of reducing inequalities in oral health. European Journal of Dental Education, 16: 195-201. https://doi.org/10.1111/j.1600-0579.2012.00736.x
³ Mac Giolla Phadraig C., Mccallion P., Mcglinchey E., Cleary E.,Nunn J. et al. (2015) Total tooth loss and complete denture use in older adults with intellectual disabilities in Ireland. Journal of Public Health Dentistry,75 (2): 101-8.
4 NHS England (2015), Guides for commissioning dental specialities – Special Care Dentistry.