AMERICAN ACADEMY OF DEVELOPMENTAL MEDICINE & DENTISTRY

Preparing Dental Students and Practitioners to Provide Care for Individuals with Disabilities

BY H. BARRY WALDMAN, DDS, MPH, PHD, STEVEN P. PERLMAN, DDS, MSCD, DHL (HON), ALLEN WONG, DDS, EDD AND BARBIE VARTANIAN

"While dentists, in serving the public, may exercise reasonable discretion in selecting patients for their practices, dentists shall not refuse to accept patients into their practice or dental services to patients because of the patient's race, creed, color, gender, sexual orientation, gender identity, national origin or disability." 1 (emphasis added) ADA Code of Ethics

Advisory Opinion "As is the case with all patients, when considering the treatment of patients with a physical, intellectual or developmental disability or disabilities… the individual dentist should determine if he or she has the need of another's skills, knowledge, equipment, or expertise, and if so, consultation or referral… hereof is indicated. Decisions regarding the type of dental treatment provided, or referrals made or suggested, should be made on the same basis as they are made with other patients." 1 ADA Code of Ethics

The American Academy of Developmental Medicine and Dentistry (AADMD) was organized in 2002 to provide a forum for healthcare professionals who provide clinical care to people with neurodevelopmental disorders and intellectual disabilities (ND/ID). The mission of the organization is to improve the quality and assure the parity of healthcare for individuals with neurodevelopmental disorders and intellectual disabilities throughout the lifespan.

"The American Dental Association revised its code of ethics (in response to efforts by the National Council on Disabilities) to prohibit denial of care to patients with physical, developmental or intellectual disabilities. In cases where a dentist does not have the equipment or expertise to meet a particular person's disabilities, the code now requires them to refer the patients to an appropriate dentist rather than simply turning them away." 2

BACKGROUND

It was not until 2004, that the U.S. Commission on Dental Accreditation (CODA) adopted a new standard (with implementation in 2006) stating that "Graduates must (sic) be competent in assessing the treatment needs of patients with special needs." 3

However, the standard (as adopted) did not require hands-on clinical experience during dental school training. Subsequent to the establishment of the new standard, a study of the clinical experience in the care individuals with disabilities indicated that some dental schools had supplemented their curriculum to include clinical experiences in the care of these patients.4

In 2019, the ADA Code of Ethics was modified to include two additional words referring to the refusal by dentists to treat patients. It now stated: "…dentists shall not refuse to accept patients into their practice or dental services to patients because of the patient's race, creed, color, gender, sexual orientation, gender identity, national origin or disability." 1

Current dental practitioners: There are barriers in preparing current practitioners to provide care to individuals with disabilities, i.e. the dentists who graduated from dental schools prior to implementation of the CODA programmatic standard. Although an increasing number of state dental licensing boards require dentists to complete a defined number of mandatory continuing education hours as a precondition for relicensure, they do not specify courses for the care of individuals with disabilities. The fact is that a review of state education requirements and education programs in the larger dental conventions provide few, if any courses, for the care of these individuals. For example:

EACH AND EVERY ONE: Many current practitioners do provide needed care for their patients with disabilities. However, the ADA Code of Professional Conduct now includes the statement that all practitioners shall not refuse to accept patients, including those with a disability.

1.The Massachusetts Dental Society "Yankee Institute" listing of license renewal approved continuing education courses in 2019 for dentists, dental hygienists and dental assistants has a listing of programs including: infection control, eating disorders, oral cancer, radiology, ethics, sleep apnea, management, etc. but none related to the care of people with disabilities. 5 There was one single listing in 2016 for "Success and preparation for patients with special needs."6 An e-mail inquiry was sent to the presenter of this continuing education course regarding the makeup of the audience. The following was the response: "On average, I do get a wonderful turnout for my programs (usually over 100 and sometimes close to 200 for the larger meetings) but in general, the room is full of mostly dental hygienists and dental assistants." (emphasis added) (Personal communication with the presenter) One course is listed in 2019 Yankee Dental Congress, "Special Needs Patients" presented by one of us (SPP), while one would get continuing education credit, it is not mandatory for license renewal.7

2.A review of the 2018 Greater New York Dental Meeting Program and Exhibit Guide provided the following information regarding sessions for the care of individuals with "special needs" or "disabilities":

• In 2017, there were 52,733 individuals registered for the meeting.

• In the 200 page program Topic Index Listing, one afternoon session was listed under the section for patients with disabilities offered by a nurse, "Pharmacologic Management of the Geriatric Patient."

• A second presentation not listed in the index, and most difficult to find was offered by one of us (SPP); "How general dentists can improve the oral health of the disabled and

those at risk (medically complex and elderly)" was placed under a Public Health Symposium category. Far less than 100 dental assistant, dental hygienists and dentists attended the session.

• The only other use of the word "disability" in the 200-page listings was a notice, telephone and e-mail numbers for those registrants in need of "disability-related accommodations or wheelchair access information." 8

THE REALITY

There are tens of millions of individuals with disabilities who have care needs in our communities. Preparing dental school graduates to provide these services is a critical step that the Commission on Dental Accreditation is considering as it reviews updating the standards (in line with new ethics obligations) to include hands-on clinical experience for the care of these disabilities. For example, specialty care clinics (such as New York University School of Dentistry and Penn Dental Medicine's Center for People with Disabilities) are: 1) engaging alumni by providing continuing education opportunities for the provision of care to individuals with disabilities, and 2) offering the opportunity for graduates to observe at chairside in an effort to gain a better understanding of the individual patient.

Yes, many current practitioners do provide needed care for their patients with disabilities. However, the ADA Code of Professional Conduct now includes the statement that ALL practitioners shall not refuse to accept patients (including those with a) DISABILITY.

Surely, the profession and the state licensing authorities will adopt a step in the process to prepare current practitioners to provide the needed services for individuals with disabilities. If not mandatory requirements at the time of license renewal, how else? •

ABOUT THE AUTHORS:

H. Barry Waldman, DDS, MPH, PhD is a SUNY Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, NY. E-mail: h.waldman@stonybrook.edu. Steven P. Perlman, DDS, MScD, DHL (Hon) is the Global Clinical Director and founder, Special Olympics, Special Smiles; and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine. Allen Wong is Professor at University of the Pacific, Arthur A. Dugoni, School of Dentistry, San Francisco CA, and Global Clinical Advisor, Special Olympics. Barbie Vartanian is Executive Director, Project Accessible Oral Health, Viscardi Center, Albertson, NY.

References

1. American Dental Association Code of Professional Conduct (Patient Selection and Advisory Opinion 4.A.1. Patients with Disabilities or blood borne pathogens) November 2018. Available from: ada.org/en/about-the-ada/principles-of-ethics-code-of professional-conduct Accessed March 6, 2019.

2. Bernhard B. Disability Scoop. Dentists no longer permitted to turn away patients due to disabilities. Available from: dis abilityscoop.com/2019/0/28/dentists-turn-away-disabilities/26093 Accessed March 6, 2019.

3. Commission on Dental Accreditation (2014) Accreditation standards for dental education. Chicago: American Dental Association.

4. Clemetson JC, Jones DL, Lacey, et al. Preparing dental students to treat patients with special needs: changes in predoctoral education after the revised accreditation standard. Journal Dental Education 2013;76(11)1457-1465.

5. The Massachusetts Dental Society "Yankee Institute" listing of license renewal approved continuing education courses programs, 2019. Available from: yankeedental.com/Attendees/Search-for-Course-programs Accessed March 7, 2019.

6. Massachusetts Dental Society, Yankee Institute (2016) Continuing education. Available from: massdental.org/ce/schedule.aspx Accessed December 18, 2017.

7. Yankee Dental Congress, 2019. Available from: google.com/search/?q=yankee+dental+congress+2019 +courses&rlz=1C1CHBF_enUS800US800&oq=2019+Yankee+Den tal+Congress&aqs=chrome.1.012j69i61.5124j0j8&sourceid=chrom e&ie=UTF-8. Accessed March 8, 2019.

8. Greater New York Dental Meeting Program Guide. Available from: nxtbook.com/nxtbooks/gnydm/programguide2018/index.php#/1 Accessed March 7, 2019.