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A national shortage of dentists is biting across all areas of the sector but nowhere is this being more keenly felt than in the special needs dentistry (SND) sector, as Tracey Porter discovers.
Neuro diverse patients are missing out on much needed care because of a shortage of dentists prepared to tackle the many professional and financial barriers involved in treating those with complex medical issues.
But leading practitioners say the problems don’t end there. They say they are being compounded by a reluctance to seek assistance by some special needs patients and their caregivers because of a perception that their dentist is inadequately trained in SND and concerns about their level of empathy.
Special needs dentistry was officially recognised as a dental specialty in Australia in 2003 with special needs dentists typically undertaking additional postgraduate training after attaining their dental degree.
However, with only around 20 SND members listed with peak body The Australia New Zealand Academy of Special Needs Dentistry (ANZSND), it is clear demand for this service outweighs the number of practitioners able to deliver it.
Dr Hajer Derbi, the convener of postgraduate training in special needs dentistry at the University of Melbourne, says a number of factors have contributed to the dearth of dentists choosing to specialise in SND, including aspects of patients’ cooperation, cognitive capacity and communication.
The SND patient population is growing at a rapid rate, a problem that is being exacerbated by the fact that life expectancy of special needs patients—which include those with intellectual disabilities, and/or medical, physical or psychiatric conditions, or a combination of both—is greatly increased.
Dr Derbi says SND is a unique discipline because unlike other specialties, it requires knowledge in all aspects of general dentistry and medicine.
“As a consequence, it requires specialists to be trained to treat their patients by taking a holistic approach of oral health and liaising with all those members of an individual’s care team including not only medical professionals but also the social team to understand the social aspects of our patients,” she says.
Dr Helen Marchant became a specialist in SND in 2005 after developing an interest in the specialty when working as a dental advisor for the Department of Health. It was through this role she managed a review of the dental services at a residential facility for people with intellectual disabilities and was awakened to what she calls “the institutionalised nature of the provision of dental care (consistent with every other aspect of residents’ lives) with no, or limited, family involvement and a ‘one-size-fits-all’ approach”.
This inspired her to become an advocate for change, and after being involved in dental programs for people affected by HIV/AIDS, mental health issues, drugs, alcohol and homelessness, she decided SND was her “calling”.
In 2006 she gave birth to her son, who is autistic, and in 2016 she opened her own private practice, Western Special Needs Dentistry, where she currently sees around 40 patients per week living with autism, Down syndrome, cerebral palsy or other special needs.
Dr Marchant says her experience enables her to connect with patients’ parents. This makes them more amenable to her utilising single tooth anaesthesia as a more comfortable way of delivering local anaesthetic and providing iPads or sensory toys to create a more pleasant experience during procedures.
“I feel I can give advice from a lived experience and from the heart, not just from a textbook. For example, dentists can be quite judgemental about diet choices. I know how difficult it is to feed an autistic child, so I can be more realistic in advising parents.
“My patients often have several people involved in their care, and the most successful outcomes are achieved when we all work together. All my patients are different and have very specific, individual needs.”
But Dr Derbi says it is because SND patients require more than routine delivery of care that some dentists are put off choosing SND as their specialty.
Instead it requires a lot of skills to minimise the barriers that may limit the individual’s capacity to undertake oral hygiene activities, exercise habits that promote oral health, and utilise oral health care services on a regular basis, she says.
Dr Derbi says there are also professional and financial barriers general dental practitioners identify, making them reluctant to provide specialised care for patients with special needs.
“These include perceived limited formal educational preparation in special needs dentistry, limited financial incentives, and the perception of added intrusions into practice dynamics and the increased complexities of care for individuals with intellectual, developmental or other disabilities.”
Dr Derbi, who is in the middle of a research project exploring the perception of newly graduated students/dentists in treating patients with SND, says by far the biggest hurdle to be overcome in terms of attracting more dentists to try SND is a lack of education.
The “generally accepted consensus” is that student experience in these specialised environments is an essential component of formal SND undergraduate training, where it helps to enhances confidence, knowledge and skills, she says.
“Understanding the role of general practitioners in providing oral health care for patients with special needs, especially with the low number of SND specialists in Australia, results in dental schools having the responsibility of preparing graduates to become competent clinicians equipped with scientific knowledge, positive attitudes and clinical skills towards addressing the oral health care needs of these patients.”
For this reason, Dr Derbi argues the design of the curriculum is key in achieving the required level of knowledge, skills and behaviour during education and training.
She says it has been well documented that dentists who were trained in SND during their undergraduate years treated more patients with special needs. It has been shown they also had better attitudes towards providing care for this population, compared to dentists who were not trained at undergraduate level.
Dr Derbi argues a national effort is needed to make the necessary changes to transform the experience of people with special needs in having more inclusive communities.
There is also a significant need for improving special care dentistry training and increasing the number of general dentists that are able and willing to treat adults with special needs, she says.
“Increased experience for general dentists through residency training and CPD courses will help to increase competence and knowledge in the practice of special care dentistry, since it will take some time before sufficient SND specialists are available to cater for the 4.2 million individuals with advanced health care needs.”