Dentists’ perception of barriers to dental care for children with special health care needs in bengaluru, india

INTRODUCTION

The American Academy of Paediatric Dentistry defines special health care needs as those which include any physical, developmental, mental, sensory, behavioural, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for individuals with special needs requires specialized knowledge acquired by additional training, as well as increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine.¹

The Census 2011 showed that, in India, 20.42 lakh children aged 0-6 years are disabled. Thus, one in every 100 children in the age group 0-6 years suffered from some type of disability.² Children with special health care needs (CSHCN) are among the most underserved in our society(3) and what makes it more ominous is the fact that these children have a higher incidence of dental caries, periodontal diseases or dental trauma.^4,5,6 The encumbrance of the oral diseases in these individuals adds to the existing psychological, emotional and financial burden caused by the already existing medical condition.

Improving attitude towards access, treatment, and quality of care of CSHCN is a critical public health issue for our profession. Literature search revealed that dentists traditionally have been reported as being reluctant to provide dental services to people with disabilities and also significantly inadequate level of comprehensive dental services are provided to these patients. The reasons for this reluctance are numerous and identification of such barriers can be the first step in addressing the deficiencies.⁷

Hence this study was undertaken with the aim to explore the view of the dental practitioners in Bengaluru regarding the provision of oral health care to CSHCN and to identify the barriers and challenges clinicians face in treating this population.

Materials and Methods

The study was approved by the institutional review board. The survey instrument was a selfadministered and validated questionnaire. The validity of questionnaire was confirmed with similar literature with some modifications and with the help of senior specialists.

Hundred and fifty questionnaires were distributed to randomly selected dental practitioners in Bengaluru city. After obtaining informed consent for the participation in the study, practitioners were requested to fill in the questionnaire. Questionnaire included questions regarding the demographic details of the practitioner such as age, gender, speciality, years of experience and type of practice. CSHCN were broadly classified into children with physical disability, mental health disorder and medically compromised children. Questions regarding respondents practice patterns with these children included inquiries about whether the practioners treated CSHCN and average number of special needs children visiting them in a month.

Respondents were also asked about the treatment procedures provided by them to CSHCN and the frequently employed techniques to manage these children. A question asked respondents to identify to what degree various factors were perceived to be a barrier to their willingness to see CSHCN. For each potential barrier, they could choose “high, medium, low, or no” as ratings.

Questions concerning respondents’ confidence levels in treating CSHCN included in quiries about how they rate their training in under graduate dental school to provide care for CSHCN, and whether they desired additional training in the field. Further suggestions were invited at the conclusion of the survey on what would improve the practitioners’ ability to care for CSHCN.

Thedata were analysed using SPSS version 22 (Statistical Package for the Social Sciences). Chi-square Goodness of Fit test was used to compare the distribution of participants’ responses towards different questions. The level of significance was set as p- value < 0.05.

Results

Of 150 questionnaires distributed, 114 forms were returned giving a response rate of 76%. A total of 110 forms were deemed valid based on the completion of questions. Respondents were predominantly General Dental Practitioners (56.4%) and females (54.5%) under the age group of 31- 40 years (54.5%). Of 110 surveyed dentists, majority of them (77.3%) claimed to attend to children with special health care needs in their practice. However, only about 10 percent of them stated they attend to CSHCN “Very Often” or “Often.”

Oral hygiene instructions including preventive measures (80%) and basic restorative care (72.6%) were the most commonly delivered treatments (Figure 1). Majority of dentists (93.7%) believed that CSHCN can be managed with behaviour management techniques such as TELL SHOW DO, while 5.3% recommended the use of conscious sedation, and 4.2% suggested general anaesthesia.

Dentists’ perceptions of barriers to their willingness to provide oral/ dental care to CSHCN are summarized in Figure 2. By far, the greatest barrier was concern regarding medical history, with over 50 percent of respondents identifying it as a high-level barrier followed by patient co-operation and time constraint. Among the practitioners who attend to CSHCN, 56.6% of them reported to be comfortable in managing these children in their practice. However, 95.5% of them were found to refer CSHCN to a specialist when they are encountered with the above mentioned barriers.

The facilities and services available in responding dental practices are presented in Figure 3. Even though a large proportion of practices offered treatment to CSHCN, only 28.2% of these practices were accessible by wheelchair and only 31% reported having toilet facilities suitable for disabled people.

When asked about the education or training received by the dentists, 56.4% agreed that their dental education prepared them to manage these patients. 69.1% respondents were interested in pursuing further training in managing CSHCN. However, only 17.3% of respondents have attended CDE / hands on training in treating CSHCN. Majority of the respondents felt that academic training (90%) and improved facilities & infrastructure (75.5%) would improve the quality of care to children with special needs.

DISCUSSION

Specialcare dentistry is the delivery of dental care tailored to the individual needs of patients who have disabling medical conditions or psychological limitations that require consideration beyond routine approaches.⁸

Survey of healthcare providers is an important tool for assessing healthcare practices and the settings in which care is delivered. Thus,the current research is across-sectional study that aimed at exploring the view of the dental practitioners in Bengaluru regarding the provision of oral health care to CSHCN and to identify the barriers and challenges clinicians face in treating this population. This study focused on CSHCN rather than abroader population of special needs patients that includes adults and the elderly.

The findings from the survey showed that majority of the surveyed practitioners attend to CSHCN in their practice. However, only 3.6% of them encountered more than 3 such patients in a month. Similar findings were reported in a study conducted in Kerala, India by Adyanthaya et al (2017).⁹

The most common treatment procedures provided by these practitioners attending to CSHCN reported in this study included oral hygiene instructions, preventive treatments and basic restorative care and majority of them managed these procedures with behaviour management techniques. However, when providing more invasive procedures, the respondents preferred to refer these children to specialists such as paediatricians, paediatric dentists.

Concern regarding medical history was identified by the surveyed population as the major barrier in treating CSHCN followed by patient co-operation and time constraint, while only a few (13%) reported financial issues as an obstacle. This is contradictory to the findings of Milano M and Seybold SV (2002)¹⁰ who reported insufficient financial reimbursement as the major barrier. Thestudy conducted by Adyanthaya et al (2017)⁹ in Kerala, India, reported lack of training and experience as the major barrier for managing disabled children and as reported by Chadha et al (2015)¹² in Mangalore, the major barrier identified by the dentists in treating patients with special health care needs was communication difficulties.

Our data also shows that majority of the clinics are not equipped with the practice facilities suitable to accommodate disabled. Similar findings were reported in studies conducted by Adyanthaya et al (2017) in Kerala9 and Chadha et al (2015)¹¹ in Mangalore. It is imperative to point that only 17.6% of the dentists participated in this study considered lack of practice facilities as a barrier to provide dental care for CSHCN.

Most of the practitioners (56.4%) agreed that their dental education prepared them to manage CSHCN and 69.1% respondents were interested in pursuing further training in managing these patients. The constructive finding in the current study is that dentists expressed their consensus about the need for more education and their willingness to attain more education and training in providing oral / dental care for CSHCN. However, only 17.3% of respondents have attended CDE / hands on training in treating CSHCN.

This finding highlights the need for incorporation of evidence-based education and hands on training for management of CSHCN. An imperative inference in this regard would be in the same lines as Casamassimo¹² who suggested that educational programs toward the care of special needs patients do not necessarily increase the number of dentists willing to care for these patients, but rather reinforce the resolve of those practitioners who want to eliminate the disparity faced by children with special needs in obtaining adequate care.

The limitation of this study is that the data collected is subject to response bias and recall bias. Also this study included 38 dentists who had an institution based dental practice, which might have resulted in higher than actual reporting for facilities to accommodate CSHCN. Further studies should be conducted in a larger population.

CONCLUSION

Our findings conclude that majority of dentists attend to CSHCN in their practice and are willing to provide simple treatments. Concern regarding the medical history and patient co-operation were found to be major barriers encountered by the practitioners. Minimizing the barriers is essential to provide comprehensive dental care to CSHCN. Steps must be taken to increase the knowledge of the dentist regarding management of CSHCN by improving academic training. To equip future dental graduates in dealing with this group of patients better, clinical exposure of students to this population should occur.