CDA Journal-JUNE 2022: Oral Health Care for People With Special Health Care Needs: A Call to Action by California Dental Association

Journa C A L I F O R N I A

D E N TA L

June 2022 Curriculum Modifications Medical-Dental Integration Care Coordination

A S S O C I AT I O N

ORAL HEALTH CARE FOR PEOPLE WITH SPECIAL HEALTH CARE NEEDS: A CALL TO ACTION

Nº 6

J U N E 2022

Vol 50

Ray E. Stewart, DMD, MS, and Ben Meisel, MD

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June 2022

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d e pa r t m e n t s

309 Guest Editorial/State of the CDA Foundation 311 Impressions 371 RM Matters/Patient Dismissals: Why, When and How 375 Regulatory Compliance/OCR Cybersecurity Newsletter: Securing Your Legacy (System Security)

377 Tech Trends

311 f e at u r e s

315 Oral Health Care for People With Special Health Care Needs: A Call To Action An introduction to the issue. Ray E. Stewart, DMD, MS, and Ben Meisel, MD

317 Oral Health Care for Californians With Special Health Care Needs: A Problem in Need of a Solution This paper addresses the chronic problem of reduced access to care faced by those with special health care needs. Ray E. Stewart, DMD, MS, and Ben Meisel, MD

325

Predoctoral Curriculum Modifications in Caring for Patients With Special Health Care Needs This article discusses the implications of revised CODA Accreditation Standard 2-25 and suggestions for dental curriculum modifications. Allen Wong, DDS, EdD, and Paul Subar, DDS, EdD

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Medical-Dental Integration: A Promising Approach To Address Unmet Dental Needs of Children and Youth With Special Health Care Needs This review discusses how a medical-dental integration and a patient-centered approach may address the unmet dental needs of children and youth with special health care needs. Karen Raju, BDS, MPH; Yogita Butani Thakur, DDS, MS; Cambria Garell, MD; and Irene V. Hilton, DDS, MPH C.E. Credit

345 Strategies To Reduce the Use of General Anesthesia for Children and Adolescents With Special Health Care Needs: Dental Desensitization and ‘Shorten the Line’ Models This paper describes two models of reducing indications and referral for dental care with sedation and/or general anesthesia. Jean Calvo, DDS, MPH; Paul Glassman DDS, MA, MBA; Tara Glavin, MA, BCBA; and Helen Mo, DMD, MS CON TINUE S ON PAGE 307

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Journa C A L I F O R N I A

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

CDA Officers Ariane R. Terlet, DDS President president@cda.org John L. Blake, DDS President-Elect presidentelect@cda.org

D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Alicia Malaby Communications Director

Editorial Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org Ruchi K. Sahota, DDS, CDE Associate Editor

Carliza Marcos, DDS Vice President vicepresident@cda.org

Marisa K. Watanabe, DDS, MS Associate Editor

Max Martinez, DDS Secretary secretary@cda.org

Gayle Mathe, RDH Senior Editor

Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Judee Tippett-Whyte, DDS Immediate Past President pastpresident@cda.org

Volume 50 Number 6 June 2022

A S S O C I AT I O N

Jack F. Conley, DDS Editor Emeritus Robert E. Horseman, DDS Humorist Emeritus

Production Danielle Foster Senior Visual Designer

Upcoming Topics July/Dental Benefits Policy August/Dental Radiology September/ Precision Medicine

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Ray E. Stewart, DMD, MS, and Ben Meisel, MD Guest Editors Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Journal of the California Dental Association Editorial Board Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif. Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

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352 C.E. Credit Worksheet This worksheet provides readers an opportunity to review C.E. questions in this issue before taking the C.E. test online. This test counts as 0.5 of Core C.E. 353 NYU Dentistry Oral Health Center for People With Disabilities This paper shares the vision of the NYU Dentistry Oral Health Center for People With Disabilities and encourages other dental schools to embrace this vision. Ronald W. Kosinski, DMD

359 Care Coordination: A Valuable Adjunct To Dental Practice — Lessons Learned in a Public Health Setting This paper presents the results of a care coordination pilot in two federally qualified health centers that worked with community dental care coordinators. Ellen Darius, RDH, MS, MPH; Huong Le, DDS, MA; Sridevi Ponnala, BDS,DDS, MBA; and Curtis Le, DMD

367 Billing for Extra Time Needed To Treat Individuals With Special Needs This paper discusses CDT Code D9920, which allows providers to be compensated for extra time required to provide care to the underserved population with special health care needs. Allen Wong, DDS, EdD, and Ellen Darius, RDH, MS, MPH

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Guest Editorial

C D A J O U R N A L , V O L 5 0 , Nº 6

State of the CDA Foundation Richard Graham, DDS Chair, CDA Foundation Board of Directors

t has been a challenging two years. As CDA members, we are all too aware that providing dental care to patients since March 16, 2020, has changed significantly. All of us must share a sense that our profession will never be the same — another one of those seminal events that reshapes our lives in countless ways. As current chair of the CDA Foundation Board of Directors, I have been asked to share some insight as to our activities, some that have been profoundly affected by the SARSCoV-2 pandemic and others that have continued with little or no interruption. The CDA Foundation was founded in 2001 with the primary mission to improve the oral health of Californians by supporting the dental profession in its efforts to meet community needs. To that end, a number of programs have been established over the succeeding years: ■ The Student Loan Repayment Grant helps new graduates reduce their indebtedness in exchange for a commitment to practice in underserved areas. To date, 22 dentists have been awarded this grant. ■ In partnership with the University of California, San Francisco, research was funded and published in the effort to manage caries risk through assessment procedures, also known as CAMBRA. ■ In partnership with Henry Schein Cares, the Foundation has established the Dental Materials and Supplies Grant. Nonprofit organizations are recipients of this award and receive dental supplies that help provide dental care in underserved communities.

Along with the delivery of care to individuals in need, the (CDA Cares) events have also drawn media and public attention to the plight of the underserved.

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In a combined effort with the California Society of Pediatric Dentistry, the Foundation created the Pediatric Oral Health Access Program for underserved children. This program has evolved into the Treating Young Kids Everyday (TYKE) program, an online course designed to increase dentists’ confidence to see babies and young children and inspire a commitment to decreasing the prevalence of dental caries in California’s children. The program is available online at cda.org and has been completed by approximately 5,900 dental professionals. To help meet the needs of our dependent seniors, the Foundation developed and successfully piloted the Geriatric Oral Health Access Program to test an innovative model of care in which registered dental hygienists in alternative practice (RDHAP) partnered with facility dentists to perform assessments, develop oral health treatment plans and deliver appropriate hygiene protocols to improve the oral health services provided to residents in long-term care facilities. In response to natural disasters, including the devastating wildfires that have wracked colleagues up

and down the state, the Foundation has distributed funds to dental professionals whose homes and businesses were damaged or destroyed. ■ Most recently, Foundation relief efforts have included providing a portal for member donations to be collected and delivered to our colleagues and their patients in Ukraine. The most visible example of Foundation efforts has been the creation of the CDA Cares program. The first CDA Cares event was held in 2012 and has been repeated at rotating venues across the state. To date, CDA Cares has provided over $25 million dollars in oral health care with more than 30,000 individuals receiving treatment. Along with the delivery of care to individuals in need, the events have also drawn media and public attention to the plight of the underserved. As a result, policymakers in Sacramento have addressed issues like adding adult Medi-Cal dental benefits back into the state budget. On a personal note, my involvement with the CDA Foundation began in 2014 when I was asked to volunteer at a CDA Cares event in Vallejo, California. My assignment was to help manage a relatively small group of volunteers who would medically screen potential CDA Cares patients prior to receiving JUNE 2 0 2 2

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treatment. It was an unforgettable experience — so many patients, so many volunteers and so much activity. Those of you who have volunteered can relate. For those of you who haven’t volunteered, please consider getting involved with the Foundation efforts at any level — you will be amazed at how good it feels. In conjunction with the Harbor Dental Society, the Foundation was preparing to host a CDA Cares event in Long Beach in July 2020; however, the arrival of the SARS-CoV-2 virus in the spring of 2020 put a halt to any event that would bring together the number of individuals that we see at a typical event. While we continue to evaluate the option of returning to a large-scale event, we have been refocusing our efforts on delivering care to individuals in need through utilizing small venues where we can mitigate risk for patients and volunteers alike. However, additional opportunities to improve public health have arisen. The Foundation received a $1 million dollar grant to facilitate increasing COVID-19 and flu vaccine confidence among dental professionals and patients. With the help of CDA, the Foundation helped to establish a vaccine confidence toolkit and provided several webinars for dentists interested in volunteering at mass vaccination sites and, more recently, offering flu and COVID-19 vaccines in office. Other funding has helped our efforts. Notably, the Foundation received a $3 million dollar grant to help deliver care via CDA Cares and current alternative efforts as we wait for a return to a large event format. In addition, funding from the Delta Dental Foundation has allowed the creation of the Smile Crew CA dental assisting bootcamp program to assist with workforce development.

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We are also looking at ways to focus Foundation efforts on the changing health care landscape in California. Due in part to the way awareness of CDA Cares events have impacted state lawmaker budget priorities, we are no longer in the same landscape we once were over a decade ago. Significant ongoing investments have been made in the Medi-Cal Dental Program — a state oral health director and office of oral health were created and dental coverage is more available to those eligible for safety net programs. While the need for dental care persists, the Foundation is at a precipice in its strategic planning process to prioritize how it can invest its programmatic resources in health equity initiatives to expand provider ability to treat broader patient bases that historically have been underserved including Black and Hispanic communities, individuals with special health care needs and patients living in more remote areas of the state. We will continue to look at other alternative ways to fulfill the Foundation’s mission on a scale that can be managed safely. Utilizing existing facilities with volunteers and resources are interim solutions that we are pursuing as well as looking for less traditional ways to provide assistance. Lastly, I want to thank all of those individuals who have contributed to the Foundation’s efforts from the beginning, either through donations of time, money or supplies. A great number of people have participated in bringing aid and relief to the people of California through the years by assisting the CDA Foundation as directors and volunteers at the state and local level. I am but one volunteer in a long line who has contributed to the evolution of the

Foundation to make it what it is today. I have had the pleasure of meeting and volunteering with many of you over the last few years. I want you to know that the good deeds continue, and we will always strive to fulfill the charitable mission — regardless of the detours that cause us to pause and pivot. n Richard Graham, DDS, is the chair of the CDA Foundation Board of Directors. A leader in the dental community, his service includes membership on the CDA Board of Trustees and CDA Practice Support Workgroup. He has actively served in various capacities on the Foundation’s board since 2018. Dr. Graham is a general dentist practicing in Rohnert Park, California.

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

Impressions

C D A J O U R N A L , V O L 5 0 , Nº 6

New Cell Type Could Help Restore Salivary Glands

(Credit: Mauduit et al. Licensed under Creative Commons CC BY-NC 4.0.)

Scientists at Scripps Research and the National Institute of Dental and Craniofacial Research have discovered a special type of cell that resides in salivary glands and is likely crucial for oral health. The research was published in the journal Cell Reports in April. The new type of salivary gland cell is called “ionocyte” and works to maintain healthy concentrations of charged molecules — ions — of potassium, calcium, chlorine and other electrolytes in saliva. The scientists also found that this type of ionocyte secretes a key growth factor, fibroblast growth factor 10 (FGF10), suggesting that it has a further role in the repair of salivary glands after injury. “These are unique cells, and we hope that by studying them we can develop better treatments for the many medical conditions that affect salivary glands and related glands such as tear glands,” said Helen Makarenkova, PhD, co-senior author of the study. Saliva contains enzymes that assist in digestion, antibodies and other immune elements to protect against infection and finely tuned concentrations of different ions to maintain the overall health of teeth and oral tissues. Salivary glands can be damaged by cancer-related radiation therapy in the head and neck region and other medical conditions including autoimmune disorders. The research team focused first on a growth factor protein called FGF10, which is important for the early development of salivary glands and is suspected to have a maintenance and repair function in adult salivary glands. The scientists’ aim was to discover the cell type that produces FGF10 in adult salivary glands. The team analyzed large single cell atlases of mouse gene activity and isolated FGF10-expressing cells for in-depth gene expression analysis. They found that while mesenchymal cells called fibroblasts produce FGF10 in very young mice, a very different cell type — a type of salivary duct-lining epithelial cell — takes over production starting in the second week of life. The researchers showed that this FGF10-producing epithelial cell has molecular markers indicating that it is an ionocyte, an evolutionarily ancient cell type that maintains proper levels of ions and related molecules in local tissues. Among the products of this ionocyte observed by the research team is the cystic fibrosis transmembrane conductance regulator protein (CFTR). This protein is best known as the cause of cystic fibrosis when it is absent in lungs through inherited mutation. However, it is also known to have an important role in salivary and tear glands, where its deficiency contributes to a common, inflammatory, dry-mouth/dry-eye syndrome called Sjögren’s syndrome. The identification of the cell type that produces CFTR in the adult salivary gland might lead to better therapies for this syndrome, the researchers said. n

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Carbs, Sugar Impact Oral Microbiome of Older Women How Flossing and Brushing May Be Good for Lungs European Union scientists are investigating whether good oral hygiene can help prevent chronic lung diseases and what saliva says about overall health, according to an article in Horizon: The EU Research & Innovation Magazine. “We believe that inflammatory bacteria in the mouth create pockets between the gum and tooth, break down the lining and spread to the heart and lungs,” said Randi Bertelsen, PhD, of the University of Bergen in Norway. Whether mouth bacteria influence the health of our lungs and future risk of lung disease is the focus of a project led by Dr. Bertelsen. The project involves hundreds of participants in a previous study, the European Community Respiratory Health Survey, who were monitored for respiratory health over the last two decades and who had given samples from their gums around 10 years ago. With further research now underway under the BRuSH project, Dr. Bertelsen is investigating the role played by the oral microbiome in lung disease. Her hypothesis is that oral microbiome communities dominated by bacteria will have a negative effect on the respiratory tract. The time scale of the experiment may help reveal whether deteriorating dental health is indeed a preamble to lung disease, indicating that bacteria in the mouth are detrimental to lung health or not. Dr. Bertelsen is especially interested in asthma and chronic obstructive pulmonary disease (COPD), two incurable lung diseases. 312

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Scientists from the University at Buffalo have shown how eating sugary and high glycemic foods, like doughnuts and other baked goods, regular soft drinks, breads and nonfat yogurts, impacts the oral microbiome of postmenopausal women. In a Scientific Reports study, the UB-led research team investigated whether carbohydrates and sucrose (table sugar) were associated with the diversity and composition of oral bacteria in a sample of 1,204 postmenopausal women using data from the Women’s Health Initiative. The study was the first to examine carbohydrate intake and the subgingival microbiome in a sample consisting exclusively of postmenopausal women and was unique because samples were taken from subgingival plaque. “This is important because the oral bacteria involved in periodontal disease are primarily residing in the subgingival plaque,” said study first author Amy Millen, PhD, associate professor of epidemiology and environmental health in UB’s School of Public Health and Health Professions. The research team reported positive associations between total carbohydrates, glycemic load and sucrose and Streptococcus mutans. But the team also observed associations between carbohydrates and the oral microbiome that are not as well established, such as Leptotrichia species, which have been associated with gingivitis in some studies. The other bacteria they identified as associated with carbohydrate intake or glycemic load have not been previously appreciated as contributing to periodontal disease in the literature or in this cohort of women, according to the research team. The key question now is what this all means for overall health, and that’s not as easily understood just yet. “As more studies are conducted looking at the oral microbiome using similar sequencing techniques and progression or development of periodontal disease over time, we might begin to make better inferences about how diet relates to the oral microbiome and periodontal disease,” Dr. Millen said.

Patients with severe lung disease, such as COPD, often have severe gum disease too, but it is unclear which comes first. To resolve this, the BRuSH project will investigate by enrolling young patients with mild to moderate gum disease. Dentists will treat away bacteria from their mouth, and saliva and blood samples will be taken before and after the procedure.

If removing the bacteria leads to better lung health, this will demonstrate that oral hygiene is far more important for lung health than previously thought and underline just how important toothbrushing, flossing between teeth and dental visits are in young adults for their future lung health.

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Double-Stranded RNA Induces Bone Loss Tokyo University of Agriculture and Technology researchers report a new discovery regarding the mechanisms for bone loss in periodontitis. They found that double-stranded RNA molecules can activate the immune system response that leads to deterioration of bone. The study was published in the Journal of Biological Chemistry. The main components of outer

membranes of the bacteria that cause periodontitis are molecules called lipopolysaccharides, which support the bacterial cell and protect against attack of immune cells. But lipopolysaccharides have also been implicated in causing gum inflammation by switching on toll-like receptors (TLR4) on immune cells that then recognize the bacteria as pathogens. However, until now it was unclear

Dental Implants Fail in Patients Reporting Penicillin Allergy Dental implants are more than twice as likely to fail in people who report an allergy to penicillin and are given alternative antibiotics compared to those given amoxicillin, according to a new study by the NYU College of Dentistry published in Clinical Implant Dentistry and Related Research. Previous studies have shown that patients with a penicillin allergy experience higher rates of dental implant failure, but they have not looked at which alternative antibiotics were used. To understand the outcomes of taking different antibiotics, researchers reviewed the charts of patients who received dental implants, documenting which antibiotics were given and if their dental implant was successful. The sample included 434 patients who reported having a penicillin allergy as well as a random sample of 404 patients without the allergy. All patients without a penicillin allergy were given amoxicillin, while those who reported an allergy were given alternative antibiotics: clindamycin, azithromycin, ciprofloxacin or metronidazole. The researchers found that dental implants failed in 17.1% of patients who reported a penicillin allergy, compared to 8.4% of patients without an allergy. Patients who took the alternative antibiotics were much less likely to have successful dental implants; the failure rate for patients taking clindamycin was 19.9% and 30.8% for azithromycin. Additionally, patients with an allergy to penicillin were more likely to experience earlier failure of their dental implant than those without an allergy. The reason dental implants failed in patients with a penicillin allergy is unknown, researchers said, but it could be attributed to reactions to the material used in implants or inefficacy of the alternative antibiotics.

Mouse alveolar bones were collected and teeth were removed to prepare organ cultures of alveolar bone. (Credit: Tominari et al. Licensed under Creative Commons CC BY-NC 4.0.)

whether “other pathogens including double-stranded RNA (dsRNA) derived from bacteria or autologous cells contribute to the progression of periodontal bone loss,” said study author Masaki Inada, DDSc, PhD, professor in the department of biotechnology and life science. Using osteoblasts and bone marrow cells from mice, plus a synthetic molecule analogous to dsRNA, researchers experimented with exposure of the cells to dsRNA. They observed that the dsRNA clearly induced the differentiation of more osteoclasts, the cells that break down bone. The dsRNA caused osteoblasts to produce more of the hormone-like PGE2 that in turn upregulated the protein RANKL and stimulated osteoclasts to differentiate. So the osteoblasts, through interactions with the dsRNA molecules, sent cellular signals that increased the production of the bone-eroding osteoclasts. The dsRNA also made mature osteoclasts survive longer. More longer-surviving osteoclasts lead to more adsorption of bone when gums are inflamed from bacterial disease. The study revealed a previously unknown mechanism by which gum disease causes breakdown of bones, suggesting that TLR3 signaling in stromal osteoblast controls PGE2 production and induces the subsequent differentiation and survival of mature osteoclasts. The stromal osteoclasts lead to inflammatory resorption of bones anchoring the teeth. Knowing that the inflammation leading to bone damage in periodontitis can be set off by dsRNA introduced via the bacteria or accumulated immune cells in tissues is progress in combatting the effects of periodontitis. JUNE 2 0 2 2

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Oral Health Care for People With Special Health Care Needs: A Call to Action Ray E. Stewart DMD, MS, and Ben Meisel, MD

GUEST EDITORS Ray E. Stewart, DMD, MS, is a professor and chair of pediatric dentistry at the University of California, San Francisco. He has spent his career providing oral health services to children who are medically compromised or have other special health care needs. He is currently leading an effort to expand the availability of preventive and early interventional services to special needs patients of all ages throughout Northern California. Conflict of Interest Disclosure: None reported.

Ben Meisel, MD, or “Dr. Ben,” is a pediatrician focused on improving the lives of children with special health care needs (SHCN). He is the medical director of California Children’s Services, San Francisco, a professor of pediatrics at the University of California, San Francisco and former medical director of the medical camp The Painted Turtle. Dr. Ben is also an award-winning children’s recording artist and the founder of Dr. Ben & Company “Building Play Into Health,” a platform for development of childhoodempowering music, educational gaming and kids’ health entertainment for children with SHCN. Conflict of Interest Disclosure: None reported.

e are pleased to serve as editors of this curated edition of the Journal of the California Dental Association devoted to the subject of oral health care in the special health care needs (SHCN) population. This is a critical time for special needs dentistry, as there is a growing awareness and sense of urgency among state and local officials to address the persistent inequities and lack of access to basic oral health care services. We are hopeful that once they are made aware of this chronic health justice problem, legislators, community leaders, SHCN advocates and others will embrace the moral and ethical obligation to find a solution in California and beyond — working to provide the dental profession with the resources and incentives necessary to adequately address this serious problem. Furthermore, with inadequate access to preventive and restorative dental care for people with SHCN, who are the most at risk for medical complications and

hospitalization, there is a significant fiscal incentive to reduce the high number of emergency room visits and frequent need for general anesthesia dental services that become necessary as a result of delayed or unmet dental care. It is appropriate to note that to begin to address this particular concern, as this issue goes to print, CDA is asking the California State Legislature for a one-time allocation of $50 million to establish a grant program that will build or expand stand-alone oral health care centers for people with SHCN to receive oral health care. It is our hope that the reader will become more aware of the scope and magnitude of the unmet health care needs in the SHCN population as described in the article “Oral Health Care for Californians With Special Health Care Needs: A Problem in Need of a Solution” and will be introduced to some innovative approaches that are being applied in the search for solutions to this nationwide problem.

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Solutions such as: ■ Efforts and recent policy modifications intended to change dental education and curriculum to better prepare future generations of practitioners to willingly and confidently accept SHCN patients into their practices. See the article “Predoctoral Curriculum Modifications in Caring for Patients With Special Health Care Needs.” ■ Efforts to address the unmet oral health needs of the SHCN population by more closely integrating medical and dental providers. See the article “MedicalDental Integration: A Promising Approach To Address Unmet Dental Needs of Children and Youth With Special Health Care Needs.” ■ Efforts to develop alternative methods of delivering preventive and early interventional oral health services to the SHCN population at locations and facilities where they live, thereby reducing both the

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dependence on care under general anesthesia as well as the major travel burden further impacting families. See the article “Strategies To Reduce the Use of General Anesthesia for Children and Adolescents With Special Health Care Needs: Dental Desensitization and ‘Shorten the Line’ Models.” Suggestions on the creation, design and equipping of facilities specifically intended to serve the SHCN population as well as how to modify an office environment to improve access to care by becoming SHCN patient friendly. See the article “The NYU Dentistry Oral Health Center for People With Disabilities.” Suggestions on incorporating the concept of “care coordination” into practice workflow to facilitate better patient/caregiver/provider communication and eliminate the frequency of cancellations and appointment no-shows, which otherwise may frequently occur.

See the article “Care Coordination: A Valuable Adjunct to Dental Practice — Lessons Learned in a Public Health Setting.” ■ Discussion of the California Department of Health Care Services policy allowing providers to bill for the extra time it takes them to treat individuals with special needs. See the article “Billing for Extra Time Needed To Treat Individuals With Special Needs.” Over the last decade, California has made significant progress in reducing barriers to oral health care, and each year we see more and more individuals receive coverage and care. However, our SCHN population has been left behind and improvements at the system and local level are still desperately needed. We hope this issue of the Journal inspires you to take another look at your practice and see how you can actively become part of the solution. n

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Oral Health Care For Californians With Special Health Care Needs: A Chronic Problem in Need of a Solution Ray E. Stewart DMD, MS, and Ben Meisel, MD

abstract This manuscript sets the stage for the other articles in this issue pertaining to the current status of dental care for persons with special health care needs in California and addressing the chronic problem of reduced access to care faced by this population. The lack of access to oral health care experienced by the 7 million special health care needs (SHCN) patients in California serves as a proxy for the rest of the nation where there are too few providers who are adequately trained for and/or comfortable in accepting SHCN patients in their practices. This issue of the Journal explores the root causes of these disparities and offers potential solutions moving forward. Keywords: Special needs dentistry

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AUTHORS Ray E. Stewart, DMD, MS, is a professor and chair of pediatric dentistry at the University of California, San Francisco. He has spent his career providing oral health services to children who are medically compromised or have other special health care needs. Dr. Stewart is currently leading an effort to expand the availability of preventive and early interventional services to special needs patients of all ages throughout Northern California. Conflict of Interest Disclosure: None reported.

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Ben Meisel, MD, or “Dr. Ben,” is a pediatrician focused on improving the lives of children with special health care needs (SHCN). He is the medical director of California Children’s Services, San Francisco, a professor of pediatrics at the University of California, San Francisco and the former medical director of the medical camp The Painted Turtle. Dr. Ben is also an award-winning children’s recording artist and the founder of Dr. Ben & Company “Building Play Into Health,” a platform for development of childhoodempowering music, educational gaming and kids’ health entertainment for children with SHCN. Conflict of Interest Disclosure: None reported.

t has long been recognized that the chronic lack of access to oral health care for persons with special health care needs (SHCN) is a nationwide problem. While the reasons for this inequity are multiple and vary from state to state, in California the primary causes of the disparities that confront this population can be attributed to three primary deficiencies: ■ Inadequate number of adequately trained general dentists equipped to treat adult SHCN patients. ■ Lack of appreciation of the size of the SHCN population and the magnitude of the disparities in health care status that arise from the systematic exclusion and barriers that exist for access to oral health care services by the public, policymakers and legislators. ■ Inadequate resources dedicated to overcoming the barriers to care (financial, physical and geographic) that confront SHCN patients, their families and/or caregivers. The purpose of this paper is to explore the origins of these deficiencies and to offer possible solutions and resolutions to a situation that has existed for decades and has resulted in significant and chronic disparities in access to care for the SHCN population. A person with SHCN is defined by the American Academy of Pediatric Dentistry (AAPD) as one who has “any physical, developmental, sensory, behavioral, cognitive or emotional impairment or limiting condition that requires medical management, health care intervention and/or use of specialized services or programs.” The Maternal Child Health Bureau defines a child with SHCN as those “who have or are at risk for a chronic physical, developmental, behavioral or emotional condition and who also

require health and related services of a type or amount beyond that required by children generally.” These definitions include a wide range of developmental or acquired disabilities with varying degrees of severity. A single individual with SHCN may manifest one or several health-related issues. The majority (78.4%) of patients with SHCN manifest one or more conditions described in the FIGURE . 1 An estimate of the number of patients who qualify as having SHCN in any geographic location is difficult to determine because census data or other populationbased studies have not focused specifically on this population. On a national level, an approximation of the number of children (below age 21) who have SHCN is 18.5% (13.6 million), and 1 in 4 households (24.8%) have one or more children with SHCN.2 There are no similar statistics for the populations over age 21; however, with the growing number of medical problems that occur with age and with the onset of dementia and need for assisted living, the estimate will significantly increase. In the 2001 National Survey of Children with Special Health Care Needs, dental care was among the largest of unmet needs,3 a finding that has remained consistent for nearly two decades.3–5 The specific category of dental care for children with SHCN has been reviewed and compared with healthy children.5,6 Parents of children with SHCN are more likely to report unmet dental care needs in their children compared with unaffected children.7-9 In California, there has been little success in tracking dental health status in persons with SHCN. Previous attempts to do so have failed due to the lack of comprehensive claims data or populationbased assessments. The Lucile Packard Foundation for Children’s Health at Stanford University attempted to track

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Percent of USA children ages 3-17yo Down syndrome Cystic fibrosis

dental health data on children with special health needs but reported “we have not found reliable data to report on dental care for children and youth with special health care needs.” To address this problem in the future, we will need to identify a way to accurately measure and track the oral health needs of the SHCN population. Without specific data and information that would be derived from a well-planned and executed needs assessment, we are left with “best estimates” based on prevalence of developmental disabilities per 1,000 population as tallied by the National Survey of Children’s Health (NSCH) Data Resource Center, which estimates the SHCN population at 18.5% of the total population. The 32 counties in Northern California have a total population of 14,389,000.10 Using the 19% population estimate would mean that approximately 2,734,000 persons in Northern California have SHCN. In the San Francisco Bay Area alone, with a population of 7,235,000, a 19% SHCN population means that there are 1,374,650 people with SHCN, most of whom depend on the Medicaid system to provide health care services. It quickly becomes obvious that the volume and unmet demand for care far exceeds the current health care system’s ability to provide even basic oral health care services for the SHCN population. With fewer than 40% of practicing dentists in California participating in the Medi-Cal Dental Program, there is not a reasonable expectation that the current workforce is capable of meeting the needs of this population.

Access To Care: Barriers Faced by the SHCN Population

Patients with SHCN face significant disparities in general health care status that may arise from unconscious bias, discrimination, lack of access to care or

Tourette syndrome Arthritis Cerebral palsy Diabetes mellitus Blood disorders Epilepsy Heart condition Hearing disorder Vision disorder Autism spectrum disorder Behavioral/conduct problems Asthma Anxiety

FIGURE . Health-related issues in the special health care needs population. (Source: childhealthdata.org 2017-18.)

systematic exclusion from health care services in general.9–12 More specifically, they also face significant barriers to oral health care. These barriers may be either environmental/system-centered or nonenvironmental.13 Environmental barriers to obtaining oral health care include difficulties finding a dental office close to home that accepts the patient’s dental insurance and is able to accommodate the patient’s unique needs.11 Nonenvironmental factors are those that concern the patient and may include those with developmental disabilities, complex health care issues, behavioral issues, dental phobias, patient anxiety or oral defensiveness, all of which may make it difficult for an SHCN patient to tolerate dental treatment in a traditional office setting.13 In spite of these many limitations, it is important to realize that many SHCN patients can be treated in the traditional clinical setting with modest alterations that allow proper access without the increased medical risk or additional

cost of general anesthesia. However, the provision of this care will invariably require additional time and involve the use of properly trained providers and auxiliary personnel or the use of advanced behavior management techniques to complete an examination or procedure.15 A principal reason that a disparity exists in access to care for SHCN patients seeking dental services is that too few providers are properly trained and willing to serve this population of patients, especially adults. In general, most general dentists lack adequate training and do not feel comfortable accepting SHCN patients into their practices. Even fewer are equipped or willing to provide services at settings such as schools, day care, special education centers, residential facilities and longer-term care facilities. Many providers who might otherwise be willing to see SHCN patients decide not to due to the extra time and effort required to collect and evaluate a complex medical/social history, acquire necessary consents (when complex legal JUNE 2 0 2 2

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relationships exist around guardianship and decision making) and accurately determine whether their practice is, or is not, a good match for an SHCN patient. Those few providers and practices that do elect to provide care for the SHCN population and do participate in the MediCal Dental Program are so overwhelmed by the demand for their services that a two to three year wait for appointments is not unusual. Such delays in care often result in serious complications. Routine, nonacute oral health issues often progress to become acute emergencies requiring emergency department visits or, worse yet, hospitalization for treatment under general anesthesia. Oral health needs that could have been addressed preventively now escalate to the need for much higher risk and more costly care. Not infrequently, patients with SHCN suffer from multiple associated medical conditions that become intensified and complicated by the coexistence of untreated dental disease. This failure to recognize the direct relationship between poor oral health and poor general health propagates a downward spiral, frequently resulting in the utilization of emergency services or hospitalization to treat a resulting acute medical condition. Lack of insurance coverage, low Medicaid reimbursement, high out-ofpocket expense and high deductibles are frequently cited as common financial barriers that disproportionately burden families of patients with SHCN when seeking medically necessary oral health care.13,16–20 Additional environmental- and system-centered barriers to care are related to the financial aspects of reimbursement by third-party payers and particularly their willingness to compensate for the additional time required to provide dental care for individuals with SHCN.14 Patients with significant medical complexity require longer face-to-face 320

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appointments to review a thorough history as well as additional nonfaceto-face time for medical consultations, documentation and care coordination.21–23 Possible solutions to these problems exist in the form of potential payment reforms including the implementation of and reimbursement of codes such as CDT code D9920 discussed elsewhere in this issue that would allow dental providers to follow an important trend similar to those of their medical colleagues who currently utilize reimbursable “prolonged service codes” (CPT codes 99354 and 99356).24

Access to basic services through school and safety-net sites varies greatly and is especially sparse in rural communities.

Similarly, the recognition of the value of care coordination activities for patients with SHCN could reform the current system that responds to episodic needs of patients to being one that is more systematically proactive and comprehensive,25 thereby reducing the incidence of hospitalizations and avoiding costly emergency department visits.26

Dental Care for Pediatric SHCN Patients

Federal regulations (Section 1905 of the Social Security Act and Title 42 Code of Federal Regulations (CFR) Section 441.50) guarantee access to oral health care services for all children aged 0 to 21 through the Early and Periodic Screening, Diagnostic and Treatment (ESPDT) program. This mandate

would seem to assure that all children and adolescents, including those with SHCN, have access to comprehensive oral health services. Unfortunately, the reality is that the SHCN population is one that primarily relies upon the Medicaid dental benefits for basic oral health care services and the low patientprovider ratio virtually guarantees a lack of access to basic oral health care services for many of those with SHCN. Fortunately, in California, there is a robust safety-net system of federally qualified health centers (FQHCs) and community health centers through which California SHCN patients aged 0 to 21 are able to obtain basic preventive, restorative and surgical services. Additionally, California’s existing dentistry training programs (five pediatric dentistry, 16 general practice and seven advanced education in general dentistry) located at dental schools and university hospitals throughout the state are available to provide care to the SHCN population. Access to basic services through these school and safetynet sites varies greatly and is especially sparse in rural communities. At best, nonemergency, new patient appointments for SHCN patients covered by Medicaid often require wait times of several weeks to several months. For older pediatric SHCN patients (aged 16 to 21) requiring nonemergency restorative or surgical care under general anesthesia, the wait time can be as great as 12 to 36 months. Children aged 0 to 16 with SHCN have traditionally received their oral health care from the pediatric dentistry community. Pediatric dentistry training programs incorporate significant portions of their didactic curriculum and clinical experience to the care and treatment of SHCN patients. Although most pediatric dentists in private practice do not accept Medi-Cal Dental as reimbursement for their services, the majority do see

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children and adolescents with SHCN whose parents have private insurance. In addition, there are many safety-net programs in California including the FQHC networks and university-based pediatric dentistry training programs that see large numbers of child and adolescent SHCN patients for routine preventive oral health care. Some of these safetynet programs, especially the university programs, provide comprehensive restorative and surgical services to this population up to approximately age 16 to 17. It is an entirely different world for older patients with SHCN who face a situation where there are very few general dentists who have been properly trained or are willing to assume the oral health care of the adult SHCN population.27–29,32 The relatively small number and distribution of pediatric dentists means that broader involvement by general dentists is necessary to address access to care issues, especially transition from pediatric to adult care for patients with SHCN.29

Dental Care for Adults With SHCN

It is widely recognized and published that adults with SHCN face numerous, sometimes onerous, obstacles in obtaining basic health care services as compared to the general population.27 Access to oral health care services is foremost among the specific unmet health care services for the population with SHCN upon reaching adulthood when their oral health care needs may go beyond the scope of the pediatric dentist’s expertise. At this point, it may no longer be in the young adult’s best interest to be treated solely in a pediatric facility.28,29 Only 10% of surveyed general dentists reported that they treat patients with SHCN often or very often, while 70% reported that they rarely or never treat patients with SHCN.34 A survey revealed that most

pediatric dentists help patients with SHCN transition into adult care, but the principal barrier is the availability of general dentists and specialists willing to accept these patients.35 A 2005 survey of senior dental students noted that the provision of oral health care to patients with special needs was among the top four topics in which they were least prepared.30 This self-perceived lack of preparation of future dentists bodes poorly for effective transitioning of adult patients with SHCN. Improving training at the predoctoral and postdoctoral

Only 10% of surveyed general dentists reported that they treat patients with SHCN often or very often.

levels is needed to increase the general practitioners’ skills and comfort for treating patients with SHCN.33–38 The AAPD recognizes the importance of transitioning patients with SHCN to an adult dental home as they reach the age of majority. Finding a dental home to address their special circumstances while providing all aspects of oral care in a comprehensive, continuously accessible, coordinated and family-centered manner has proven to be a formidable challenge in California and elsewhere.39 Recognizing the problems associated with the transition from pediatric to adult care are formidable, and in an attempt to improve health care transition for adolescents with SHCN and young adults with chronic conditions, a policy statement was established by several

medical organizations.38 The policy statement articulated six critical steps to ensuring the successful transition to adult-oriented care. These policies, although made for medical providers, can also apply to dental providers and oral health delivery systems as well. They are: ■ To ensure that all young people with special health care needs have a health care provider who takes specific responsibility for transition in the broader context of care coordination and health care planning. ■ To identify the core competencies required by health care providers to render developmentally appropriate health care and health care transition and ensure that the skills are taught to primary care providers and are an integral component of their certification requirements. ■ To develop a portable, accessible, electronic medical record to facilitate the smooth collaboration and transfer of care among and between health care professionals. ■ To develop an up-to-date detailed written transition plan, in collaboration with the patient and their family. ■ To ensure that the same standards for primary and preventive health care are applied to young SHCN people with chronic conditions as to their peers. ■ To ensure that affordable, comprehensive, continuous health insurance is available to young people with chronic health conditions throughout adolescence and into adulthood. When patients with SHCN reach late adolescence and early adulthood, they begin to develop dental and medical problems specific to adulthood that are beyond the scope of pediatric practice. JUNE 2 0 2 2

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At this age, they also begin to encounter significant difficulty accessing oral health care. Beginning at age 16 to 17, few pediatric dentists continue to treat the SHCN population, and the vast majority of general dentists, regardless of practice setting, do not have the requisite training or experience.39-41 An additional barrier occurs at age 26 when SHCN patients are no longer covered by their parent’s or guardian’s private insurance. Most must then rely upon various publicly subsidized programs, further intensifying the oral health care access problem. A survey revealed that most pediatric dentists help patients with SHCN transition into adult care, but the principal barrier is the availability of general dentists and specialists willing to accept these patients. Improving training at the predoctoral and postdoctoral levels is needed to increase the general practitioner’s skills and comfort for treating patients with SHCN.31–33 Addressing the manpower issue is of utmost importance. Training and instruction for health care providers can be obtained through postdoctoral educational courses. In the U.S., programs such as general practice residencies and advanced education in general dentistry provide opportunity for additional medical, behavior guidance and restorative training needed to treat patients with SHCN. The Special Care Dentistry Association fellowship and diplomate programs and the Academy of General Dentistry’s mastership program also may provide opportunities to increase workforce competency.33–35 One notable example of an attempt to address the issue of lack of access to oral health care for adult patients with SHCN is San Francisco’s University of the Pacific, Arthur A. Dugoni School of Dentistry (UOP). Dr. Paul Subar and Dr. Allen Wong have created a special care clinic 322

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offering services to adults and adolescents with significant behavioral/ developmental needs. Due to overwhelming demand, there is still a long waiting list for routine dental appointments. They also offer dental care general anesthesia utilizing the operating rooms (OR) at partner medical institution California Pacific Medical Center. Though this attempt is admirable, due to limited OR availability for dentists, wait times for nonurgent treatment under general anesthesia can be as much as three years. It is abundantly clear that additional facilities as well as

Due to overwhelming demand, there is still a long waiting list for routine dental appointments.

alternative methods for delivering care to SHCN patients, ideally located in remote and underserved communities, are necessary if we are to meet the enormous needs of this population. The majority of adult patients with SHCN throughout California are beneficiaries of the Medi-Cal Dental Program and depend on this system for their oral health care needs. California is unique in this regard, as it is one of the few states that provide a dental benefit to adults enrolled in Medicaid. However, only 20% of California dentists in private practice accept Medi-Cal Dental patients. Thus, most patients with SHCN older than age 17 are forced to rely on the safety-net system of community health/ FQHC health center network to receive essential oral health care services. Most

of the providers within this safety-net system do not have the training or experience required to treat patients with SHCN. These providers subsequently refer patients with SHCN to tertiary care medical centers and advanced education training facilities for routine and emergency services. Tertiary medical centers and advanced education training facilities are overwhelmed with the demand; thus, leading to 24- to 36-month waiting lists for services.

UCSF Special Needs Dentistry Summit On Feb. 12, 2020, University of California, San Francisco, School of Dentistry Dean Michael Reddy, DDS, hosted a national symposium (referred to as a "summit") addressing access to care problems faced by the SHCN community in California. Attendees represented various stakeholder groups and experts in the field of SHCN dentistry from California and across the nation who recognize that there is a significant segment of our population, those with SHCN, who have been neglected with respect to having access to basic oral health care services. These stakeholders reached a consensus that, under the direction of the Department of Health Services and state universities collaborating with the entire California oral health community, now is the time to correct this inequity and to develop and implement a strategy to eliminate this unconscionable injustice. A solution to this problem in California will require the broad support of legislators and policymakers in state government, informed by patients, families, caregivers and providers. Patient and family advocacy programs like Family Voices of California must educate lawmakers and push for change. The UCSF Special Needs Dentistry Summit was a first step toward outlining a pathway

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forward to providing basic preventive and early intervention oral health services to California’s most vulnerable and dependent citizens. The proceedings of the symposium with specific outcomes and recommendations were published in a white paper currently available on the UCSF website.42 A summary of specific summit outcomes and recommendations follow.

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Specific Summit Outcomes and Recommendations ■

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Identify resources and fund a Special Needs Population Survey and Needs Assessment Pilot Project in Northern California (if not the entire state). Survey methodology could be shared and replicated throughout California. This survey and needs assessment would likely best be undertaken by the office of the California State Dental Director in collaboration with the various county health departments, with the assistance of the divisions of public health dentistry at UCSF and UCLA as well as the California Dental Association. The data derived from this survey and needs assessment is necessary as a baseline against which to measure any changes in access to care and the provision of increased levels of oral health care services (e.g., preventive and restorative services) to this population over time. UCSF in collaboration with other partner institutions and universities with schools of dentistry and public health programs should continue to lead this initiative and identify resources necessary to support the project. A logical first step would be the formation of an interdisciplinary advisory group consisting of local and regional stakeholders to develop evidence-based policies/

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protocols for serving the population with SHCN in California. Proactively plan and pursue a legislative agenda designed to provide more state and federal funding for programs dedicated to improving access to oral health care for the population with SHCN. Undertake a feasibility study to develop a network of dedicated special needs dental centers (similar to the centers recently established in New York, Pennsylvania and Arizona.) Promote the formation of a joint

The proceedings of the symposium were published in a white paper currently available on the UCSF website.

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UCSF/UOP/UCLA taskforce hosted by CDA to brainstorm best practices and to mount a unified statewide approach to supporting the adoption of legislation and policy development described previously. Develop an interinstitutional curriculum, as required by the Council on Dental Accreditation (CODA), to provide all California predoctoral dental students sufficient training and experience working with patients with SHCN. This effort might best be achieved by utilizing the existing curriculum developed by the UOP faculty. A new CODA guideline (Standard 2-25) specifically addresses the necessity of training predoctoral dental students to provide care to the population

with SHCN under the “Clinical Sciences Specific Standard Relating to Special Needs,” which states: Standard 2-25: Graduates must be competent in assessing and managing the treatment of patients with special needs. Intent: An appropriate patient pool should be available to provide experiences that may include patients whose medical, physical, psychological or social situations make it necessary to consider a wide range of assessment and care options. As defined by the school, these individuals may include, but are not limited to, people with developmental disabilities, cognitive impairment, complex medical problems, significant physical limitations and the vulnerable elderly. Clinical instruction and experience with the patients with special needs should include instruction in proper communication techniques including the use of respectful nomenclature, assessing the treatment needs compatible with the special need and providing services or referral as appropriate. ■ Explore the possibility of creating or expanding existing GPR/AEGD programs at California’s existing dental training programs. Encourage predoctoral elective opportunities with primary care advanced training programs that emphasize SHCN care (GPR, AEGD, pediatric dentistry). ■ Form an interagency council between DHCS, DDS and CDPH to advocate for the expansion of the Medi-Cal Dental case management services. Case management is a valuable asset to assist practices, to facilitate completion of paperwork, gather necessary consents and properly match patients with an appropriate dental provider. This interagency dental council could also partner with CDA to fund a special needs dentistry professorship at each advanced training program in the state. This network of experts would provide JUNE 2 0 2 2

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a credible network of advocates for consistent standards, educational and clinical guidelines and the development of oral health care policy for the population with SHCN. Support the design and development of a robust virtual dental home/ telehealth system. University-based faculty providers could virtually supervise and support ancillary personnel (RDH, RDA, RDA/EF) giving care to patients where they live. This would effectively reduce the need and demand for secondary and tertiary care under general anesthesia for the population with SHCN. n

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11. Kerins C, Casamassimo PS, Ciesla D, Lee Y, Seale NS. A preliminary analysis of the U.S. dental health care system’s capacity to treat children with special health care needs. Pediatr Dent Mar–Apr 2011;33(2):107–12. 12. Norwood KW, Slayton RL, Council on Children with Disabilities Section on Oral Health. Oral health care for children with developmental disabilities. Pediatrics 2013 Mar;131(3):614–9. doi: 10.1542/peds.2012-3650. Epub 2013 Feb 25. 13. Nelson LP, Getzin A, Graham D, et al. Unmet dental needs and barriers to care for children with significant special health care needs. Pediatr Dent Jan–Feb 2011;33(1):29–36. 14. Webb JR. Overview of disability. In: Nelson TM, Webb JR, eds. Dental Care for Children With Special Needs. Cham, Switzerland: Springer; 2019:51–2. 15. Mattson G, Kuo DZ, AAP Committee on Psychosocial Aspects of Child and Family Health, AAP Council on Children with Disabilities. Psychosocial factors in children and youth with special health care needs and their families. Pediatrics 2019 Jan;143(1):e20183171. doi: 10.1542/peds.2018-3171. 16. Bayarsaikhan Z, Cruz S, Neff J, Chi DL. Transitioning from pediatric dental care to adult care for adolescents with special needs: Dentist perspectives (Part Two). Pediatr Dent Sep–Oct 2015;37(5):447–51. 17. Bachman SS, Comeau M, Long TF. Statement of the problem: Health reform, value-based purchasing, alternative payment strategies and children and youth with special health care needs. Pediatrics 2017 May;139(Suppl 2):S89–S98. doi: 10.1542/peds.2016-2786C. 18. Rouleau T, Harrington A, Brennan M, et al. Receipt of dental care and barriers encountered by persons with disabilities. Spec Care Dentist Mar–Apr 2011;31(2):63–7. doi: 10.1111/j.1754-4505.2011.00178.x. 19. Crall JJ. Improving oral health for individuals with special health care needs. Pediatr Dent Mar–Apr 2007;29(2):98– 104. 20. Kastner T, American Academy of Pediatrics Committee on Children With Disabilities. Managed care and children with special healthcare needs. Clinical Report — Guidance for the clinician in rendering pediatric care. Pediatrics 2004;114(12):1696–8. 21. Cohen E, Kuo DZ, Srivastava R. Children with medical complexity: An emerging population for clinical and research initiatives. Pediatrics 2011 Mar;127(3):529–38. doi: 10.1542/peds.2010-0910. Epub 2011 Feb 21. 22. Mount JK, Massanari RM, Teachman J. Patient care complexity as perceived by primary care physicians. Fam Syst Health 2015 Jun;33(2):137–145. doi: 10.1037/ fsh0000122. Epub 2015 Apr 20. 23. Dorlan B. Codes developed for non-face-to-face-services. American Academy of Pediatrics AAP News Coding Corner, March 6, 2019. 24. American Medical Association. Current Procedural Terminology Professional Edition: CPT: 2020. 25. Van Cleave J, Boudreau AA, McAllister J, Cooley WC, Maxwell A, Kuhlthau K. Care coordination over time in medical homes for children with special health care needs. Pediatrics 2015 Jun;135(6):1018–26. doi: 10.1542/ peds.2014-1067. Epub 2015 May 11. 26. Goodell S, Bodenheimer T, Berry-Millet R. The Synthesis Project. Care management of patients with complex health care needs. Policy Brief No. 19. Robert Wood Johnson Foundation. 2009.

27. Blum RW. Transition to adult care: Setting the stage. J Adolesc Health 1995 Jul;17(1):3–5. doi: 10.1016/1054139X(95)00073-2. 28. Chavis S, Carares G. The transition of patients with special healthcare needs from pediatric to adult based dental care: A scoping review. Pediatr Dent 2020 Mar 15;42(2): 101–9. 29. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating the transition of patients with special health care needs from pediatric to adult oral health care. J Am Dent Assoc 2010 Nov;141(11):1351–6. doi: 10.14219/jada. archive.2010.0080. 30. Chamar J, Weaver R, Valachovic R. Annual ADEA survey of dental school seniors: 2005 graduating class. J Dent Educ 2006 Mar;70(3):315–39. doi:10.1002/j.00220337.2006.70.3.tb04088.x. 31. Williams JJ, Spangler CC, Yusaf NK. Barriers to dental care access for patients with special needs in an affluent metropolitan community. Spec Care Dent Jul–Aug 2015;35(4):190–6. doi: 10.1111/scd.12110. Epub 2015 Apr 19. 32. Espinoza K. Healthcare transitions and dental care. In: Hergenroeder AC, Wiemann CM, eds. Health Care Transition: Building a Program for Adolescents and Young Adults with Chronic Illness and Disability. Cham, Switzerland: Springer International Publishing; 2018:339–49. 33. Special Care Dentistry. Fellowship in special care dentistry. 34. Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ 2004 Jan;68(1):23–5. 35. Special Care Dentistry. Diplomate in special care dentistry. 36. Academy of General Dentistry. Mastership award guidelines. 37. American Academy of Pediatric Dentistry. Symposium on lifetime oral health care for patients with special needs. Pediatr Dent 2007;29(2):92–152. 38. Rosen DS, Blum RW, Britto M, Sawyer SM, Siegle DM, Society for Adolescent Medicine. Transition to adult health care for adolescents and young adults with chronic conditions: Position paper for the Society for Adolescent Medicine. J Adolesc Health 2003 Oct;33(4):309–11. doi: 10.1016/ s1054-139x(03)00208-8. 39. American Academy of Pediatric Dentistry. Management of dental patients with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2021:287–94. 40. Geenen SJ, Powers LE, Sells W. Understanding the role of health care providers during the transition of adolescents with disabilities and special health care needs. J Adolesc Health 2003 Mar;32(3):225–33. doi: 10.1016/s1054139x(02)00396-8. 41. Newacheck PW, Hung YY, Wright KK. Racial and ethnic disparities in access to care for children with special healthcare needs. Ambul Pediatr Jul–Aug 2002;2(4):247–54. doi: 10.1367/1539-4409(2002)002<0247:raedia>2.0.co;2. 42. Stewart R, Meisel B, Mathe G, Reddy M. A Call to Action for Solving California’s Lack of Oral Health Care for Persons with Special Health Care Needs. Proceedings of a Symposium held at the University of San Francisco, School of Dentistry, February 2020. T HE CORRE S P ON DIN G AU T HOR , Ray E. Stewart DMD, MS, can be reached at Ray.Stewart@ucsf.edu.

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Predoctoral Curriculum Modifications in Caring for Patients With Special Health Care Needs Allen Wong, DDS, EdD, and Paul Subar, DDS, EdD

abstract Recent changes to educational competency standards have been implemented by the Commission on Dental Accreditation (CODA) in preparing dental students to care for patients with special health care needs. A major emphasis includes those patients with intellectual and developmental disabilities. This article offers some broad suggestions to consider when implementing curriculum changes in dental schools.

AUTHORS Allen Wong, DDS, EdD, has taught postdoctoral general dentistry for over 35 years in AEGD programs in the Bay Area and is the director of the University of the Pacific, Arthur A. Dugoni School of Dentistry’s hospital dentistry program and was the director of the Highland Hospital restorative implant program. He has lectured nationally and internationally in the areas of special care dentistry, rotary endodontics, implant restorations and minimally invasive dentistry. Conflict of Interest Disclosure: None reported.

Paul Subar, DDS, EdD, is a professor at the University of the Pacific, Arthur A. Dugoni School of Dentistry and the director of the school's special care clinic/hospital dentistry program. He specializes in access to oral health for patients with special needs, including those with severe medical, developmental and/or psychosocial conditions. Dr. Subar's clinical responsibilities include delivery of dental services to patients requiring hospital dentistry as well as responding to consultation requests from the transplant and medicine services at California Pacific Medical Center. Conflict of Interest Disclosure: None reported.

he U.S. Department of Education grants authority to the ADA Commission on Dental Accreditation (CODA) for dental school accreditation. CODA issues a series of standards that define dental school requirements for numerous topics such as administrative support, program length, faculty requirements and educational content. Dental schools must meet minimal competencies, as described in Standards for Accreditation, to maintain their accreditation. There are standards in various topics of education from administrative support to educational standards, program length and faculty. The process of modifying a CODA Standard requires a deliberate process of gathering “communities of interest” opinions and expert testimonies. Dental institutions have broad definitions for patients with special health care needs that in many cases

do not emphasize those individuals with developmental disabilities. Some dental schools are adequate in their teaching of topics in special health care needs whereas some schools do poorly in this area, particularly in content on developmental/intellectual disabilities. There was great variation in curriculum between training institutions. Some dental schools addressed providing dental care to patients with developmental/ intellectual disabilities and others did not. The American Academy of Developmental Medicine and Dentistry (AADMD) brought this ethical dilemma – the omission of dental care standards related to people with disabilities – to the National Council on Disabilities. These efforts led to the 2020 revision of CODA Standard for Accreditation 2-25 with regard to dental education and training for people with special health care needs. Standard 2-25 now specifies JUNE 2 0 2 2

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clinical instruction and experience as well as changed competency in both “assessing and managing” the treatment of patients with special needs and the manner in which care is delivered. Standard 2-25: Graduates must be competent in assessing and managing the treatment of patients with special needs. Intent: An appropriate patient pool should be available to provide experiences that may include patients whose medical, physical, psychological or social situations make it necessary to consider a wide range of assessment and care options. As defined by the school, these individuals may include, but are not limited to, people with developmental disabilities, cognitive impairment, complex medical problems, significant physical limitations, and the vulnerable elderly. Clinical instruction and experience with the patients with special needs should include instruction in proper communication techniques including the use of respectful nomenclature, assessing the treatment needs compatible with the special need, and providing services or referral as appropriate.1 It is widely accepted that the key to achieving equitable access to oral health care for patients with special health care needs and the key to alleviating this health inequity is to prepare current and future clinicians to care for populations that have been undertreated and overlooked. The recent CODA modifications in predoctoral education requirements have acknowledged the presence of care disparities for patients with special health care needs, especially those with intellectual and developmental disabilities. As we prepare for the changes in education, we need to offer a model that encourages competency and a future of sustainable access to care. In 2004, CODA attempted to address this inequity by adding the standard requirement that focused on “assessing the treatment needs of patients with special needs.” However, the change was not prescriptive 326

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enough and the literature since that time shows that academic dental institutions continued to inadequately prepare students to deal with the increasing population of individuals with special health care needs.2 Currently, in many dental schools, patients are turned away as being too complex or not able to fit the dental school’s general clinical education care model. Patients who are not accepted into the predoctoral clinics are frequently referred to one of the postdoctoral programs for care. The number of dental providers trained in postdoctoral programs is limited. The

Another historical misconception is that dental students are not interested in treating the special needs population.

postdoctoral programs that address the care of children with special health care needs are advanced education programs in pediatric dentistry. Postdoctoral programs that address special needs adult care include advanced education in general dentistry (AEGD), graduate practice residency (GPR) and specific fellowship programs. Given the limited number of postdoctoral graduates, there is a particular lack of adequately educated providers to serve young adults (age 17 and older) and older patients with special health care needs. Unfortunately, there is a prevailing implicit bias among dentists that patients with special needs require special treatment facilities. The reality is that most patients with special health care needs can be treated by most dentists with minimal adaptations required, which is

the goal of the new CODA Standards. Poor oral health of adults with intellectual and developmental disabilities (IDD) constitutes a significant health disparity in the U.S.; however, few interventions have used planning models to inform and design a theory-based strategy with potential to be both effective and sustainable in this population.3 With the new CODA Standards in place, planning continues on a humanistic model of dental education to support patients with special needs. This model must be family inclusive and incorporate the patient’s oral health needs with the needs of those who care for them. The goal should be to increase caregiver self-efficacy, patient behavioral capability and dental outcome expectancies. The dental care environment can be altered to improve self-care behavior of the adult with IDD. An example is to incorporate supported decision-making and equitable care into how care to people with IDD is taught. This is important as we strive to provide care of the whole person and not only the teeth.3 Another historical misconception is that dental students are not interested in treating the special needs population. In fact, student and resident membership in the AADMD and the Special Care Dental Association (SCDA) is growing throughout the country, with learners seeking expanded experiences in didactic and clinical venues concerned with special health care needs (SHCN) populations. A survey done a decade ago at the University of the Pacific, Arthur A. Dugoni School of Dentistry supports the assertion that more experiences (clinical and didactic) affect the willingness of dentists to treat people with special needs. The survey highlights postdoctoral graduates (those who completed AEGD/ GPR programs) as more likely and able to treat this population. It is clear that pre- and postdoctoral experiences in

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treating special needs populations play a major role in the decision of a dental graduate to enter a practice setting that serves the SHCN patient population.4 Similarly, a 2015 survey of NYU predoctoral dental students concerning their senior-year special needs rotations revealed a number of important findings: ■ Students reported a preference for treating patients in a hands-on clinical setting versus didactic instruction. ■ Clinical experiences were associated with an improved sense of self-confidence in treating patients with SHCN as well as increased future practice intentions to treat this population. ■ Increased willingness to treat SHCN patients was particularly evident among those students with the least prior experience with this population and were independent of other variables such as the students’ past experience, future goals or personality characteristics.5 In another study following provider attitudes post-graduation, alumni reported that having had more opportunities to treat patients with complex needs as predoctoral students led to a greater willingness to treat a higher number of those patients compared to alumni reporting fewer such predoctoral opportunities. Even positive perceptions may underestimate the value of educational experiences as they relate to future practice.6 For pediatric dental care, similar findings exist. Lack of exposure and experience with SHCN children in the predoctoral curriculum leads to a lack of confidence in and willingness to see pediatric patients with SHCN following graduation. As a result of these shortcomings in predoctoral education, a reluctance of the general

dental community to provide care for SHCN children is to be expected, particularly for the very young who would most benefit from the early establishment of a dental home.7 The overwhelming evidence suggests that with the implementation of the revised CODA Standard 2-25, California’s dental schools will need to address proper Americans with Disability Act-compliant facilities and increase faculty competence and predoctoral experiences for students in the care of patients with special health care needs. While it may seem challenging

Curricula are needed that generate a deeper sense of curiosity and awareness to the access-to-care problem.

to introduce additional hours into an already crowded curriculum, the results of meeting this challenge will be rewarded by improved care for the most vulnerable patients coupled with better trained, more capable clinicians. Several specific curriculum enhancements should be addressed to assure that improved patient and provider outcomes can be achieved.

Curriculum Enhancements An Integrated Model

Dental students are adult learners who matriculate into professional school with varied styles of learning acquired through many years of study.8 Learning is different for each person, and a collective experience (didactic and clinical) working with patients who have special health needs requires more than one course or

one patient experience. An integrated model of training over a multiyear curriculum that emphasizes both physical diagnosis and oral health connection is essential to training predoctoral dentists in the care of people with special needs. Dental procedures are often performed on patients who have some level of medical fragility. In many dental schools, the exercise of taking a medical history is frequently a transcription of information in the dental chart with little emphasis on the presurgical risk assessment and the development of a treatment plan appropriate to the medical status of the patient. The growing number of patients with medically complex conditions combined with the treatment advances based on current biomedical science necessitates an adaption of dental education to include a stronger basis and knowledge of systemic health. When dental and medical programs exist together, more robust medicaldental integration can help to greatly improve the quality and safety of care offered to patients with special needs.9 Improving the educational curriculum about systemic health for patients with special needs requires a curriculum that addresses implicit bias and diagnostic overshadowing. Diagnostic overshadowing occurs when a dental provider mistakenly attributes symptoms of physical ill health to a patient’s mental health, behavioral health or as being inherent in the patient’s disability. This bias can lead to a failed diagnosis and treatment. Failure of the curricula to address implicit bias and diagnostic overshadowing can lead to detrimental general health as well as oral health outcomes for vulnerable patients.10

Self-Reflection

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Curricula are needed that generate a deeper sense of curiosity and awareness of the access-to-care problem. Learning to evaluate one’s own skills through reflection and self-assessment prepares dental graduates for successfully navigating an ever-changing work environment throughout their careers. That being said, the search continues for the most effective teaching and assessment strategies to develop students’ skills in these areas.11

Physical Diagnosis

In order to empower improved access to care for vulnerable populations, graduates need to be exposed to complex health concerns in appropriate care environments for them to appreciate and learn the critical thinking skills necessary. Currently, in many dental schools, patients with special health care needs are denied access to care due to complexity. Students who have the experience of working with older and more medically complex patients gain an understanding that additional postdoctoral training may be necessary to become competent in treating more complex patients.

Supplementation/Augmentation of Current Disciplines

Disciplines such as diagnosis and treatment planning do not necessarily need to be relearned in order to serve patients with special needs. While certain aspects of the delivery of care may need to be modified, the actual discipline is no different in philosophy. For instance, a root canal is the same procedure across all patients; however, a modification in how the rubber dam is placed may be required for an SHCN patient. Additional ergonomic adjustments might be appropriate as recommended by an occupational therapist, physical therapist, behaviorist or other health provider for both patient and operator 328

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comfort. Creative reformation of current discipline curricula for more inclusivity to those with special health care needs should be considered.

Caries Risk Assessment Emphasis

The concept of caries risk-based care needs to be assessed and is particularly relevant in the SHCN population. The current predoctoral curriculum in most dental schools covers this risk-based topic of prevention; however, for patients with SHCN, there is a disconnect. New products that are noninvasive education opportunities can help to arrest dental caries and address oral biofilm concerns. Patients with SHCN often have significant gastroesophageal reflux disease or specific dietary considerations that may impact oral health. Interprofessional collaboration with primary care physicians and specialists can assist the dentist in risk-based assessment and care.

Community-Based Experiences

Partnering with organizations that support underserved or underrepresented populations can deepen the learner’s understanding of the social determinants of health and barriers to care that make health care delivery to the SHCN population such a challenge. Access to care can only be solved once providers become comfortable serving the special needs population. Community-based experiences such as Special Olympics Special Smiles events or health screenings for specific disadvantaged groups can help foster effective experiential education and reinforce the humanistic model. Partnering with organizations that support underserved or underrepresented populations can deepen the learner’s understanding of the barriers of care that make health care delivery a challenge. Such interactions from community partnerships can be as simple as virtual

presentations. A culture of service to others inculcates volunteerism, leadership and service learning.

Faculty Development

Quality education and professionalism starts with educators and mentoring of students. Although it is advantageous to have a predoctoral special care clinic, many patients with special needs can be treated in the typical dental school setting. Dental schools should consider providing active continuing education programs focusing on patients with special health care needs. This can assist the dental school in increasing the numbers of faculty who are familiar with and capable of overseeing student education in this area. Additionally, these experienced faculty can then increase the numbers of patients with special health care needs who are treated in their private practices. One by-product of this approach is an increase of volunteerism that appears to follow increased education. Providing opportunities for postdoctoral residents to provide care and teach junior dental students in a dental education setting can be a rewarding experience and grow future junior faculty. The prioritization of faculty development in this way can help to fulfill the needs for future faculty development and placement into programs.

The Pacific Dugoni Example

The following description is just one example of how one school has addressed the need for education and training in dealing with SHCN patients. Each dental school will find their strength and uniqueness. The Dugoni predoctoral experience for SHCN was created over 15 years ago. Due to an administrative reorganization, the Advanced Education in General Dentistry Program (AEGD) was closed. However,

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the demand for care of SHCN individuals and those requiring hospital-based dentistry was never greater. The Dugoni school decided to incorporate the patients and teaching of special health care needs into a senior dental school rotation. The program quickly gained popularity among faculty and students, and the patients found a caring environment to receive care and help teach future dentists. The program is structured as a mentored faculty experience with one dental assistant and five students. It starts as a four-day rotation with a hospital dentistry observation. The first day consists of an orientation to the basics of etiquette, disparity of care, some discussions of common developmental disability, medical disabilities and positioning of patients. Patients are scheduled for dental work on the remaining three days. An endof-day huddle is held to reflect on and discuss the nuances of each patient. At the end of the week, each student presents a case they have encountered during their rotation to the group to facilitate self-reflection and critical thinking skills. Prior to the pandemic’s restricted access to hospital dentistry, dental students participated in presenting the hospital dentistry case, learned about and explained the medical condition and necessary modifications to care and performed part of the dental care while the patient was under general anesthesia. To supplement these clinical experiences, students are formally assessed in their competency to manage geriatric patients and those with special health care needs. These competency examinations utilize test cases to check the students’ ability to diagnose and treatment plan based on the individual needs and physical and/or cognitive limitations of the patient. Achieving competency in these test

cases is a requirement of graduation. In 2018, a revision of the first-year biomedical science curriculum at Dugoni was undertaken to improve a common issue of basic medical science education. Prior to this change, the biological medical science curricula were separated from the teaching of clinical science. This outdated practice was rooted in the classical approach to education that does not include the contextualization of clinical and professional practice. The contemporary integrated health professional education approach emphasizes an integrated curricular model, resulting in a more meaningful student understanding of how the biomedical sciences impact clinical dental practice. This has enabled the integration of treatment considerations for SHCN populations throughout the basic science and clinical curriculum. Predoctoral students at Dugoni, and consequently the SHCN patients they serve, have benefited from the introduction of both didactic and clinical aspects of the unique needs of this population. A 2016 study of an integrated medical curriculum reflects the approach applied by Dugoni for dental education. A mere integration of basic and clinical sciences is not enough because it is necessary to emphasize the importance of humanism as well as health population sciences in medicine. It is necessary to integrate basic and clinical sciences, humanism and health population in the vertical axis, not only in the early years but also throughout the curriculum, presupposing the use of active teaching methods based on problems or cases in small groups.12 The recent changes to the CODA standard require dental schools to integrate didactic and clinical education in the training of our future oral care providers to care for patients with SHCN so that these

future dentists may be prepared and able to fulfill their ethical duty to inclusively care for all populations. n RE F E RE N C E S

1. Commission on Dental Accreditation. Accreditation Standards for Dental Education Programs. 2. Clemetson JC, et al. Preparing dental students to treat patients with special needs: Changes in predoctoral education after the revised accreditation standard. J Dent Educ 2012 Nov 76(11):1457–1465. 3. Binkley CJ, Johnson KW. Application of the PRECEDEPROCEED Planning Model in Designing an Oral Health Strategy. J Theory Pract Dent Public Health 2013 Nov;1(3):http://www.sharmilachatterjee.com/ojs-2.3.8/index. php/JTPDPH/article/view/89. PMCID: PMC4199385. 4. Subar P, et al. Pre- and postdoctoral dental education compared to practice patterns in special care dentistry. J Dent Educ 2012 Dec;76(12):1623–1628. 5. Watters AL, et al. Incorporating experiential learning techniques to improve self-efficacy in clinical special care dentistry education. J Dent Educ 2015 Sep;79(9):1016–1023. 6. Chavez EM, et al. Perceptions of predoctoral dental education and practice patterns in special care dentistry. J Dent Educ 2011 Jun;75(6):726–732. 7. Casamassimo PS, et al. Are U.S. dentists adequately trained to care for children? Pediatr Dent 2018 Mar 15;40(2):93–97. 8. Fang AL. Utilization of learning styles in dental curriculum development. N Y State Dent J 2002 Oct;68(8):34–38. 9. Dennis MJ, et al. Improving the medical curriculum in predoctoral dental education: Recommendations from the American association of oral and maxillofacial surgeons committee on predoctoral education and training. J Oral Maxillofac Surg 2017 Feb;75(2):240–244. doi: 10.1016/j. joms.2016.10.010. Epub 2016 Oct 26. 10. Clough S, Handley P. Diagnostic overshadowing in dentistry. Br Dent J 2019 Aug;227(4):311–315. doi: 10.1038/s41415-019-0623-x. 11. Gadbury-Amyot CC, et al. Measuring the level of reflective ability of predoctoral dental students: Early outcomes in an e-portfolio reflection. J Dent Educ 2019 Mar;83(3):275–280. doi: 10.21815/JDE.019.025. Epub 2019 Jan 28. 12. Quintero GA, et al. Integrated medical curriculum: Advantages and disadvantages. J Med Educ Curric Dev 2016 Oct 11;3:JMECD.S18920. doi: 10.4137/JMECD.S18920. eCollection Jan-Dec 2016. PMCID: PMC5736212. T HE CORRE S P ON DIN G AU T HOR , Allen Wong, DDS, EdD, can be reached at awong@pacific.edu.

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Medical-Dental Integration: A Promising Approach To Address Unmet Dental Needs of Children and Youth With Special Health Care Needs Karen Raju, BDS, MPH, DPH-Cert.;. Yogita Butani Thakur, DDS, MS; Cambria Garell, MD; and Irene V. Hilton, DDS, MPH

abstract Background: This review presents strategies on how medical-dental integration and a patient-centered approach may address the unmet dental needs of children and youth with special health care needs (CYSHCN). Methods: Programs, strategies and frameworks to implement medical-dental integration to improve the overall quality of life of CYSHCN were reviewed. The authors propose a patient-centered health home (PCHH) as a step toward a patient-centered approach to medical-dental integration for CYSHCN. Results: Many federal, state and local organizations have emphasized the importance of medicaldental integration. Models and frameworks to implement integrated care in multiple settings have been developed and can be applied for CYSHCN. The proposed PCHH model includes integrated education, improved clinical collaboration, integrated health information technology and integrated financing. Ravenswood clinic is an example of an organization that has developed an integrated care model that serves children and adults with special health care needs. Conclusion: CYSHCN often seek services from multiple specialties that may or may not integrate care with a patient-centered approach. It is imperative to develop care systems that make oral health an inseparable part of general health and well-being. Practical implications: The PCHH is a promising approach to improve the overall health of CYSHCN. Incorporating oral health competencies for primary care providers and increasing the skills of dental providers to care for CYSHCN are important steps. Improved communication and clinical collaboration between dental and primary care providers to increase preventive dental services to CYSHCN will reduce the burden on the health care system. However, PCHH can only be practical by reforming the health care financing system. Keywords: Special needs dentistry, vulnerable patients

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AUTHORS Karen Raju, BDS, MPH, DPH-Cert., is an associate specialist at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None reported. Yogita Butani Thakur, DDS, MS, is the chief dental officer at Ravenswood Family Health Center in East Palo Alto, California. Conflict of Interest Disclosure: None reported.

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Cambria Garell, MD, is a board-certified general pediatrician practicing primary care at Venice Family Clinic’s Simms-Mann Health and Wellness Center and pediatric multidisciplinary weight management with the UCLA Fit for Healthy Weight Program. Conflict of Interest Disclosure: None reported. Irene V. Hilton, DDS, MPH, is a staff dentist at the San Francisco Department of Health and the dental consultant for the National Network for Oral Health Access (NNOHA). Conflict of Interest Disclosure: None reported.

ental diseases have affected humans since the advent of recorded history. However, the genesis of the dental profession in the U.S. can be dated to the 1840s. Dentistry developed as a separate profession from the practice of medicine in the U.S. and this separation has continued to the present day. There are many reasons for this historical separation to have become so entrenched; however, three reasons in particular stand out: distinct paths of education and training for dentists and physicians; lack of a common electronic health record (EHR) platform; and different payment systems for medical and dental care in addition to the complex health insurance system in the U.S.1 Like many chronic disease conditions, the incidence of oral diseases is socially patterned, with an enormous burden of disease occurring among marginalized groups, including those living in poverty, racial and ethnic minorities, frail elderly, immigrant populations, those with special health care needs and others. These groups may face numerous barriers to accessing routine preventive and other dental services.2 In the U.S., the most commonly cited unmet health care needs for children with special health care needs (CSHCN) are prescription medications and dental care.3–6 Dental status is greatly influenced by social and structural determinants of health.7 Although oral health has greatly improved since the 1960s, not all Americans have equal access to these improvements.8 Older adults, especially those living in long-term care facilities, and Americans who live in rural areas and/or belong to low socioeconomic backgrounds have a higher prevalence of oral health problems and face more challenges accessing dental care.9

Individuals with disabilities also constantly encounter access barriers, regardless of their financial resources.9 The link between oral health and systemic health is well established.10 Lack of timely oral health care for people with special health care needs (SHCN) has a strong influence not only on oral health status but on the deterioration of overall health. A study assessed eight strategies to promote respiratory health in children with neurologic impairment and found that only a history of dental care was associated with decreased risk of subsequent pneumonia hospitalization.11 Despite these and other findings that demonstrate how oral health is integral to overall health, dental care remains fragmented and not integrated for CSHCN, especially those with more severe chronic conditions.5,12 This review presents strategies on how medical-dental integration and a patient-centered approach may address the unmet dental needs of children and youth with special health care needs (CYSHCN) and illustrates examples of programs that have taken a step toward a patient-centered approach to medicaldental integration for CYSHCN.

Oral Epidemiology of CYSHCN

Nearly 1 out of every 5 children in the U.S. has SHCN.13 According to the American Academy of Pediatrics (AAP), children with SHCN are “those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”14 Other agencies/organizations have defined people with special health care needs as shown in the BOX . Despite different phrases used to define this population, the primary constructs remain the same. CYSHCN

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BOX

Definition of Special Health Care Needs Agency/organization

Definition

American Academy of Pediatric Dentistry (AAPD)

“Any physical, developmental, mental, sensory, behavioral, 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 as well as increased awareness and attention, adaptation and accommodative measures beyond what are considered routine.”15

U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB)

“Those who have one or more chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.”14

National Survey of Children’s Health (NSCH)

The National Survey of Children’s Health (NSCH) is a key source of state and national data for children with special health care needs (CSHCN).16 The NSCH uses a validated screening tool to identify CSHCN and includes questions about this important subpopulation of children’s health and health care needs. The NSCH identifies special health care needs based on the health consequences a child experiences due to an ongoing health condition, regardless of diagnosis. These are categorized as: • Need or use of prescription medications. • Need or use of services. • Need or use of specialized therapies. • Functional difficulties. • Emotional, developmental or behavioral problems for which treatment or counseling is needed.

American Dental Association

“Those who due to physical, medical, developmental or cognitive conditions require special consideration when receiving dental treatment. This can include people with autism, Alzheimer’s disease, Down syndrome, spinal cord injuries and countless other conditions or injuries that can make standard dental procedures more difficult.”17

are differently abled humans who might face additional challenges accessing required dental care due to physical, behavioral or developmental conditions. Successful dental treatment requires patient cooperation and depends on good communication between patient and dentist. CYSHCN may find it difficult

to cooperate when undergoing a needed dental procedure.18 In addition, the dentist needs to have up-to-date medical information on the patient’s condition to plan safe delivery of treatment. Limited access to dental care is not the only reason for poor oral health. Complex medical conditions may affect the motor

skills needed to perform home oral hygiene. Limited speech and high pain tolerance may inhibit communication about toothaches. Physical disabilities may limit a child’s ability to sit still in a dental chair during dental visits. Additionally, sugars added to medications to enhance taste put the patient at higher risk of developing caries19 and several medications commonly used by CYSHCN cause dry mouth that also increases the risk of developing dental caries.20–22 The 2016-2018 National Survey of Children’s Health (NSCH) found that the prevalence of teeth in fair or poor condition was twice as high among CYSHCN as non-CYSHCN, and CYSHCN had higher rates of decayed teeth and cavities, toothaches and bleeding gums compared with nonCYSHCN.18 A Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents statistics on emergency department visits involving dental conditions using the 2018 Nationwide Emergency Department Sample (NEDS).23 The brief highlighted that there were more than 2 million dentalrelated emergency department visits, which represented 615.5 visits per 100,000 population in 2018. Non-Hispanic Black individuals and those residing in the lowest income communities were found to have had the highest rates of dentalrelated emergency department visits. The recent Legislative Analyst’s Office (LAO) report using Denti-Cal Claims Data (2014-2016) reported that the majority of Department of Developmental Services consumers enrolled in Denti-Cal fail to see a dentist each year as compared to the Denti-Cal beneficiaries overall.24 An analysis of data from the 2005 Medical Expenditure Panel Survey for children younger than 18 showed that some CSHCN, particularly those with more complex SHCN, were more likely JUNE 2 0 2 2

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to receive only nonpreventive care and not receive any preventive dental care services.4 However, findings from 2016-2018 parent/caregiver NSCH reported that CYSHCN have higher preventive oral health services rates, yet are significantly more likely to have poor oral health.18 This may be because of increased exposure to health care providers due to their worse oral health status, which can lead to more referrals for preventive oral health services.25 Additionally, CYSHCN with a medical home were more likely to receive preventive oral health services.18 The National Standards for Systems of Care for Children and Youth with Special Health Care Needs recognizes that CYSHCN must have access to specialty services facilitated through a medical home that coordinates care to meet medical, dental and social-emotional needs.26 Although CYSHCN were found to have more preventive oral health services, the study found that 1 in 6 CYSHCN did not have a preventive dental visit in the past year. Therefore, there were missed opportunities to integrate preventive dental care into medical homes.27

Medical-Dental Integration: A Potential Solution

Medical-dental integration is an approach to care that integrates and coordinates dental medicine into primary care and behavioral health to support individual and population health.28 This model has gained attention at the local, state and national levels as depicted in FIGURE 1. According to a recent DentaQuest report, the vast majority of patients, dentists, physicians, employers and Medicaid dental administrators believe oral health and overall health are connected and agree that greater collaboration across medical and dental providers would improve patient care.29 334

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The Substance Abuse and Mental Health Services AdministrationHealth Resources and Services Administration Center for Planning created a Standard Framework for Levels of Integrated Healthcare, outlining elements of integration to include: ■ Creating a common language to discuss integration, progress and financing. ■ Supporting assessment and benchmarking efforts. ■ Explaining integration efforts to stakeholders.

A medical-dental integration model of care adds another critical component to the dental-patient parent triad: the primary care medical provider.

Clarifying differences in vision between two or more partnering organizations.30 The framework defines key elements as follows: coordinated care to be communication, co-located care to be physical proximity of care and integrated care to reflect change in health care providers practice. Collaboration and integration are defined differently such that collaboration is how health care professionals and resources are brought together, while integration describes how services are delivered and practices are organized and managed. The California Dental Association devoted two journal issues in 2014 to medical-dental integration. The issues highlighted the importance of building a foundation for interprofessional ■

education and practice, the role of federal legislation and evolving health care systems in promoting medical-dental collaboration and bringing medical-dental integration to the private practice.31 The American Academy of Pediatric Dentistry’s best practices report on behavior guidance for pediatric dental patients promotes a continuum of interaction involving the dental team, the patient and the parent. The focus is on communication and education while also ensuring the safety of both the oral health professionals and the child during the delivery of medically necessary dental care.32 A medical-dental integration model of care adds another critical component to the dental-patientparent triad: the primary care medical provider as depicted in FIGURE 2. CYSHCN have complex medical histories and often see multiple specialists. While multispecialty clinics seem to be a great way to serve these children, one well-known model is the multidisciplinary craniofacial team clinic found across the country at large children’s hospitals. The craniofacial teams are usually multispecialty teams that focus on coordination of care often involving a pediatric dentist and an orthodontist to address the children’s oral health needs, alongside pediatricians, plastic surgeons, otolaryngologists, speech and language pathologists and social workers among other specialists. The craniofacial multidisciplinary team care model allows for opportunities to establish a dental home and provides care coordination to improve overall health outcomes. Moreover, the American Cleft Palate-Craniofacial Association has standards of approval/accreditation of multidisciplinary craniofacial teams with specific requirements around team composition, team management,

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MEDICAL-DENTAL INTEGRATION: HISTORICAL PERSPECTIVE Genesis of Dental Profession in the United States First American dental school - the Baltimore College of Dental Surgery, later part of the University of Maryland. The dental school was originally intended to be established within the medical school. It was not, but only because of lack of space and internal friction among medical school faculty. The separate evolution of Dental from Medical occurred more by chance than by intentional policy.

Dental Education at the Crossroads: Challenges and Change: The report did not call for a single medical/dental profession, but it did conclude that the dental profession will and should become more closely integrated with medicine and the health care system on all levels: education, research and patient care.

David Nash’ speech (1994) at the University of Rochester School of Medicine and Dentistry, “The Oral Physician: Creating a New Oral Health Professional for a New Century.”

1994

1840 Medical-Dental Integration American Diabetes Association Clinical Practice recommendations included dental care.

IOM Report on Dental Education at the Crossroads

Breaking the Dental-Medical Silo

Medical-Dental Integration Innovation

Recognition of importance of Oral health as an essential component of overall health by Federal Agencies

HRSA funds the first Health Disparities Collaboratives in Federally Qualified Health Centers (FQHCs), using the Chronic Care Model and Model for Improvement to improve diabetes outcomes for health center patients. Some health centers include dental care integration in their collaboratives.

Healthy People 2010 with dental objectives

British Dental Journal reports on 3-year study of integration by Haughney et al. This model of health care demonstrated the potential for coordination and integration of functions between the dental team and the primary care team. Improvement in communication by joint information exchange can be of considerable benefit to patient care.

Oral health in America: a report of the Surgeon General, issued by the Department of Health and Human Services, National Institute of Dental and Craniofacial Research, and National Institutes of Health.

2003

1995

2000

Smiles for Life: A National Oral Health Curriculum

1998 Dental/Medical Integrated insurance

Aetna’s Dental-Medical Integration Program: For pregnant members, members with diabetes, heart disease, and/or cerebrovascular disease. Enrollment for these members is automatic. There is no extra paperwork to complete by dentists or our members. The program also offers the at-risk member enhanced dental benefits that are covered in full with no deductible.

Smiles for Life: A National Oral Health Curriculum developed by the Society of Teachers of Family Medicine Group on Oral Health. The curriculum has been endorsed by over 20 national organizations.

Cigna Dental Oral Health Integration Program: For people with certain medical conditions that have been found to be associated with gum disease. The program reimburses out-of-pocket costs for specific dental services used to treat gum disease and tooth decay. The Accreditation Council for Graduate Medical Education (ACGME) adds oral health care requirements for family medicine with the aim of promoting increased resident training in oral health.

2006

2005 Health Resources and Services Administration (HRSA)

HRSA publishes the white paper, Integration of Oral Health and Primary Care Practice (IOHPCP), with the aim of improving access for early detection and preventive interventions by expanding oral health clinical competency of primary care clinicians. The white paper describes the five oral health core clinical competencies for non-dental providers. 1. Risk Assessment 2. Oral Health Evaluation 3. Preventive Interventions 4. Communication and Education 5. Interprofessional Collaborative Practice

IOM Reports

The U.S. Department of Health and Human Services commissioned the Institute of Medicine (IOM) to convene a panel of experts to examine oral health progress since 2000, and recommend actions to improve the state of oral health in America. As a result, two IOM reports were issued in 2011: 1. Advancing Oral Health in America 2. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. The second report recommends that HRSA develop oral health core competencies for health care professionals.

In October 2008 the American Academy of Pediatricians (AAP) PEDS 21 Symposium (Pediatrics for the 21st Century) focused on oral health and “the Pediatrician’s role in Oral Health.”

2009-2011

2014 Qualis Health and National Network for Oral Health Access

Supporting Oral Health in Primary Care Training

DentaQuest Foundation, Reach Healthcare Foundation and the Washington Dental Service Foundation fund Qualis Health to develop “Oral Health: An Essential Component of Primary Care” and HRSA funds the National Network for Oral Health Access to develop “A User’s Guide for Implementation of Interprofessional Oral Health Core Clinical Competencies”. Both publications provide frameworks for implementing the five oral health core clinical competencies in multiple practice settings.

HRSA funds Center for Integration of Primary Care and Oral Health (CIPCOH) to serve as a national resource for systems level research on oral health integration into primary care training.

2015

Involvement of AAMC and AAP In June 2008 the American Association of Medical Colleges (AAMC) published Contemporary Issues in Medicine: Oral Health Education for Medical and Dental Students: Medical School Objectives Project.

2016

2008 CDC’s Medical-Dental Integration Partnership Centers for Disease Control and Prevention (CDC) announced a Medical-Dental Integration partnership in October of 2020 where CDC’s division of Oral Health has awarded funding to the National Association of Chronic Disease Directors (NACDD) to develop a national framework for medical-dental integration.

2020

FIGURE 1. A historical perspective of medical-dental integration. JUNE 2 0 2 2

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patient and family communication, cultural competence, psychological and social services and assessing outcomes.33 While there has been a concerted effort to integrate dental care into primary care, such as the Center for the Integration of Primary Care and Oral Health and the Harvard School of Dental Medicine Initiative,34 there are not many well-established models in the care of CYSHCN other than with specific diagnoses, like the integrated craniofacial teams that treat cleft lip and palate and other craniofacial deformities. With the way the medical and dental practices are set up in the U.S., physical co-location of medical and dental services is not the norm, except in government-funded programs such as the Veterans Administration, Indian Health Service, federally qualified health centers, correctional facilities, etc. Co-location allows for easier access to medical and dental services for patients, and integration is further facilitated if the medical and dental providers share a common EHR. Co-located clinics with a shared EHR and infrastructure have been seen as promising pieces to achieve medical-dental integration.35 Because co-location is not the norm in most health care delivery, creative solutions are needed to achieve medicaldental integration without co-location. A wide spectrum of action steps to serve CYSHCN are needed, ranging from collaboration when needed and integration when possible. Emphasis is needed on an integrated practice of care that enables evaluation, diagnosis, prevention and/or treatment of dental diseases in a technically and emotionally supportive environment to promote the health and well-being of individuals with special health care needs. The Health Resources and Services Administration’s (HRSA) Advisory Committee on 336

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Training in Primary Care Medicine and Dentistry supports dental integration into a patient-centered medical home (PCMH) and proposed the development and evaluation of the patient-centered medical and dental home, a PCMH model that includes dentistry. This was later revised to be called the patientcentered health home (PCHH).36,37

PCHH for CYSHCN

The notion of having a dental home is to connect children to dental providers at an early age (within six

CYSHCN require individualized, coordinated, multidisciplinary and comprehensive preventive oral health services and treatment.

months of the eruption of the first tooth or by the first birthday). This early dental home concept can be characterized as a philosophy embraced by the dental practice instead of a physical location, a team that cares for patients starting in early childhood and following them through life and focusing on prevention and risk assessment.38 Although various programs and organizations have adapted and redefined the concept of a dental home, consistent elements across the dental home concept are: an ongoing relationship between dentist and patient, family-centered care and sharing many standard characteristics of a medical home (e.g., comprehensive, continuous and coordinated).39 CYSHCN require individualized,

coordinated, multidisciplinary and comprehensive preventive oral health services and treatment. FIGURE 2 depicts the PCHH for CYSHCN. Many are dependent on their parents/caregivers, primary care providers and dental provider for their health care, among other allied health professionals. All who are engaged in providing care for the patient with complex care needs should be knowledgeable about the child’s specific SHCN and interact with each other effectively and easily. PCHH can serve as a doorway to a one-stop shop for families of CYSHCN to get needed health care services without compromising the quality of these services. An ideal PCHH should be able to cater to the dental needs of CYSHCN and their families by providing them with anticipatory guidance according to patient-specific caries risk assessment, screening, the option for virtual teledentistry and easy access to preventive dental services from primary care providers and dental providers. To improve the oral health outcomes of CYSHCN, specific action steps around education, communication and payment mechanisms must be taken to truly create an integrated PCHH for CYSHCN.

Integrated Education

Interprofessional education (IPE) has been recognized as an important tool for increasing competency for all health care providers40 and has been widely accepted by dental schools.41 Interprofessional education can target a known deficit in training for pediatric providers in oral health care42,43 as well as improve competencies among dentists in caring for CYSHCN.44 Indeed, the Commission on Dental Accreditation requires that all oral health professionals receive didactic

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Patient-Centered Health Home Dental Provider

Parent/Caregiver

CYSHCN

Primary Care Provider

1. Integrated Education 2. Improved clinical collaboration 3. Integrated Health Information Technology 4. Integrated Financing

FIGURE 2 . Patient-centered health home for children and youth with special health care needs.

and clinical training on the oral health of people with special health care needs, and the AAP recommends all pediatric providers be familiar with the management and prevention of pediatric dental caries.45 For example, at the University of California, Los Angeles, the Strategic Partnership for Interprofessional Collaborative Education in Pediatric Dentistry (SPICE-PD) aims to establish an integrated oral and primary health care clinical training program for

UCLA pediatric dental residents, pediatric medical residents and nurse practitioner students. This IPE program also includes specific competencies around caring for CYSHCN including opportunities for dental residents to work alongside pediatricians and other allied professionals caring for patients with behavioral challenges, including autism. The program has trained over 300 health professional students and shows positive outcomes.44 Continuing education to increase

competencies for current practicing dental and pediatric providers will be necessary to ensure that the existing workforce can adequately care for the oral health needs of CYSHCN. The AAP has addressed the need to improve oral health training for practicing pediatricians by offering Education in Quality Improvement for Pediatric Practice on oral health best practices. This training in oral health and quality improvement allows pediatricians to obtain the required Maintenance of Certification credits required by the American Board of Pediatrics, which also offers continuing education courses on the oral health care of CYSHCN. The National Interprofessional Initiative on Oral Health funded by the DentaQuest Foundation, the Washington Dental Service Foundation, the Connecticut Health Foundation and the Reach Healthcare Foundation supports the Smiles for Life curriculum, which is endorsed by 20 national organizations and provides standardized oral health training to primary care clinicians.46 The second edition curriculum material was downloaded from the project website more than 60,000 times prior to its retirement in June 2010. In 2020, the fourth edition of Smiles for Life was released. The University of Pennsylvania, with support from Delta Dental, has initiated the “Persons with Disabilities Presentation Series,” a series of professional development programs aimed at building awareness of the barriers to equitable oral health for individuals with disabilities and developing competency to provide oral health care to this vulnerable population. This series is open to dentists and their support personnel at no charge, and participants will JUNE 2 0 2 2

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receive a certificate of completion from Penn Dental Medicine as a disabilities dentistry clinician expert after completing 18 or more of the courses within a three-year period.47 For dental providers, in-depth training around management of CYSHCN in a dental office is found within pediatric dentistry residency programs. Given the small number of pediatric dentists who graduate every year compared to general dentists, there is a need to incorporate the nonpharmacological behavior management of CYSHCN into the dental education curriculum at the predoctoral level. The training should include an integrated didactic and clinical component that would prepare the graduating dentist to be more comfortable in providing dental care to CYSHCN in a PCHH approach.

Improved Clinical Collaboration

Dental providers are vital but insufficient to address all of the unmet dental needs of CYSHCN. Several publications highlighting the oral health clinical skills/competencies for primary care providers need to be developed. In 2014, the HRSA published a white paper with five oral health core clinical competencies: risk assessment, oral health evaluation, preventive interventions, communication and education and interprofessional collaborative practice.48 In 2015, the Qualis Health and National Network for Oral Health Access (NNOHA) provided frameworks for implementing the five oral health core clinical competencies in multiple practice settings. The NNOHA approach engages members of the primary health care team in identifying and referring people who need care.49 It uses the ask, look, 338

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decide, act and document approach within the scope of primary care. The NNOHA framework took a system approach and recommended five steps to implement the five oral health core clinical competencies in safety-net systems: planning, modifying training systems, updating health information systems, modifying clinical care systems and developing evaluation systems.50 In 2003, the AAP recommended that health care professionals conduct an oral health risk assessment and in 2012 revised the risk factors

The use of evidence-based guidelines … must be increased by funding more nationwide demonstration projects in primary care settings.

and developed an oral health risk assessment tool for caries risk assessment.51 Despite this, studies report the low implementation of caries risk assessment by primary care providers.52 The “Bright Futures in Practice: Oral Health Pocket Guide” provides a structured and comprehensive approach to oral health anticipatory guidance for the health care professional.53 Additionally, the United States Preventive Services Task Force (USPSTF) has been recommending that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride and that fluoride varnish be applied to the primary teeth of all infants

and children starting at the age of primary tooth eruption.54 The use of evidence-based guidelines for screening, anticipatory guidance and oral health counseling by primary care providers must be increased by funding more nationwide demonstration projects in primary care settings. Considering the higher unmet dental needs for CYSHCN, greater emphasis must be laid on evidence-based prevention in a PCHH. The use of 38% silver diamine fluoride (SDF) is recommended to prevent and arrest cavitated carious lesions in primary teeth as part of a comprehensive caries management program.55 Moreover, a systematic review indicated that SDF at concentrations of 30% and 38% is more effective than other preventive management strategies for arresting caries in the primary dentition and shows potential as a caries preventive treatment in primary teeth and permanent first molars.56 While not yet formally recommended to be applied by primary care providers, one study found it to be feasible.57 Medical-dental integration to incorporate preventive dental strategies such as fluoride varnish application and use of SDF to arrest cavitated lesions during a medical visit became even more relevant during the COVID-19 pandemic when dental care was further delayed and withheld initially because of dental practice closures and then due to families’ fear and logistical challenges. The COVID-19 pandemic offered an opportunity for primary care providers to perform oral health assessments and reconnect patients back to their dental homes and/or establish dental homes. Effective implementation of medical-dental integrated practice requires primary care providers to have

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convenient access to a list of dental providers who accept Medi-Cal Dental and be equipped and trained in catering to people with SHCN. The PCHH approach will allow patient referral with a note on treatment needs and what special needs accommodations will be required by the patient based on their SHCN for dental care. Moreover, PCHH is also the best suited to provide behavior modification therapies like desensitization by allowing collaboration with behavioral therapists who will not only prepare CYSHCN to perform daily activities including social interactions but also ensure that they have a good dental visit experience. This is even more critical for children with hypersensitivity issues such as those with autism spectrum disorders.

Integrated Health Information Technology

An integrated electronic medicaldental record allows for bidirectional information regarding the medical and dental history between providers. Interoperability is defined as the ability of different IT systems to connect in a coordinated manner within and across organizational boundaries to access, exchange and cooperatively use data.58 Anticipatory guidance given by one discipline can be reviewed and reinforced by the other. Furthermore, caries risk assessment, treatment planning and coordination of care can be more easily accomplished through direct communication within the EHR or electronic dental record (EDR). The potential for more streamlined billing and reimbursement mechanisms can also be achieved through the integrated EHR. While a unified electronic medical-dental record is starting to be recognized as an important component of medical-dental integration,59 there

are few examples of integrated systems in the literature. An increasing number of FQHCs are moving toward integrated electronic medical-dental records. The Department of Veterans Affairs (VA) announced in late 2021 its updated plan to move forward with a systemwide EHR modernization program.60 This new system connects VA medical facilities with the Department of Defense, the U.S. Coast Guard and participating community care providers, allowing clinicians to easily access a veteran’s full medical history in one location. HealthPartners, a health

The potential for more streamlined billing and reimbursement mechanisms can also be achieved through the integrated EHR. system based in Minnesota, is one of the handful of organizations in the U.S. that uses integrated electronic medical-dental records to help improve patient outcomes collaboratively.61 Kaiser Permanente Northwest is a comprehensive health care system that serves approximately 605,000 medical members and 250,000 dental members in Oregon and Washington. It implemented medicaldental integration in 2018 that has been successful in facilitating the delivery of preventive and disease management medical services.62 Integrating health information technology allows both the primary care provider and dental provider to work jointly using the most up-todate health information of CYSHCN.

Integrated Financing

The costs of providing dental services have traditionally not kept pace with the reimbursement for services in dentistry. Cost of care has significantly gone up recently due to the COVID-19 pandemic, with dentists now needing to upgrade their personal protective equipment and their operations, while the reimbursement rates remain unchanged. Caring for CYSHCN requires a highly skilled dental team dedicated not only to dental care delivery but also to focus on care coordination, case management and managing referrals. This requires an upfront investment into operations, which adds to the cost of care delivery. These investments in personnel costs are not reimbursed and are therefore not the norm in dental practices, thus causing barriers for CYSHCN to access dental services. State Medicaid programs show low participation rates due to low reimbursement and lack of confidence treating patients with special needs.63,64 In California, only 20% of dentists participate in Medi-Cal Dental, resulting in longer wait lines for appointments, farther distance to travel and delayed dental care for patients.24 Delta Dental administers California’s Medi-Cal Dental Program. The reimbursement rates for dental procedures have been reported to be one-half to one-third of dentists’ usual fees, second to last among the six states studied by the California HealthCare Foundation.66 The lag between dental reimbursement from the state Medicaid programs and private dental insurance payers negatively impacts dentists’ participation in the Medicaid program and impacts access to dental services.66 In addition, insurance coverage, annual maximum allowances and out-of-pocket expenditures associated with obtaining dental services are all welldocumented barriers to accessing dental services.67 Both low reimbursement rates and lack of additional skilled staff negatively JUNE 2 0 2 2

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influence access to services for those with special needs enrolled in the state Medicaid program. Promoting access to oral health through a PCHH with medical-dental integration increases the costs of providing care while improving access and ultimately enhancing the oral health quality of life for patients with SHCN. A PCHH and provision of medical and dental services under one umbrella or unified health system are only possible when the payments are aligned. Value-based reimbursement models that include reimbursement for both medical and dental services and consider medical and dental outcomes would further integrate care successfully. A Medi-Cal Dental procedure code, D9920, was introduced as an adjunct code to be billed for the extra time it takes to see a patient with special needs. It is billable up to four times per year along with billable dental services. However, in some instances where children with behavioral disorders need desensitization visits, this code does not allow for reimbursement if no billable services were rendered that day. Moreover, an approximately 25% denial of claims was observed because of inadequate documentation by the dentist describing the patients’ medical conditions that required additional time for the dental visit.68 The Medi-Cal Dental Program is doing outreach to promote awareness on how to bill D9920, however, it needs more local county-level engagement to reach the clinical dental providers. In addition to increasing dental providers willingness to see CYSHCN, efforts are needed to improve the reimbursement process and the reimbursement amount paid to primary care providers to conduct a caries risk assessment, screening and counseling and provide preventive treatment. Moreover, the increased provider reimbursement rates must be supplemented with an easy administrative process.65 Furthermore, 340

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integrating the financing system can produce significant cost savings to the overall health system. For example, Aetna’s Dental-Medical Integration Program69 and Cigna’s Oral Health Integration Program70 offer integrated medical and dental benefits for members with chronic medical conditions. The business model of integrated care is characterized by integrated funding based on multiple sources of revenue, resources shared and allocated across whole practice and billing maximized for an integrated model and simple billing structure.30

A PCHH and provision of medical and dental services under one umbrella or unified health system are only possible when the payments are aligned. Dental Services for CSHCN at Ravenswood Family Health Center

Ravenswood Family Health Network is an FQHC headquartered in the low-income East Palo Alto area of San Mateo County. The clinics provide a comprehensive scope of health care services including dentistry, pediatrics, family practice and adult medicine and are a certified “patientcentered medical home.” Ravenswood’s dental clinic has served as a critical access point to oral health care for children and families in the community since 2010 and have long served children and adults with special health care needs. This has been possible with a mission-aligned vision for what is possible with a dental service delivery model unique to this FQHC rather than duplicating what is happening at other health centers or clinics.

Both pediatric and general dentists at Ravenswood have access to the operating room at a local hospital and work not only with the patient’s primary care physician to meet the needs of the patient, but also work with the hospital specialists to coordinate care. One distinction in the philosophy of care delivery at Ravenswood is the commitment to preventive care and managing CYSHCN in the dental clinics through frequent recall visits, parent education, dental desensitization and utilizing teledentistry to manage care. Several aspects of the program design described here encourage medical-dental integration although the dental clinics are not actually colocated with the medical clinics: ■ AEGD residency site: Ravenswood serves as a site for an AEGD dental residency in collaboration with NYU Langone and UCSF. As part of this program, two dental graduates spend a year gaining clinical experience at the clinic. This provides teaching opportunities to residents beyond restoring teeth to learning about essential communication skills with the physician and parents. They are actively engaged in learning about the medical considerations relevant to the patient’s dental conditions. ■ Dedicated referrals by care coordinator and OR scheduler: Ravenswood has dedicated staff who handle incoming referrals and care coordination with the medical specialists. The staff complete an intake form for CSHCN. This assists with understanding the scheduling needs of the patient in the dental office so as to successfully plan preventive and restorative care in the outpatient setting. The staff assist with coordinating patient surgeries with other specialists and are also responsible for scheduling treatment completions as part of dental

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clearances prior to patients undergoing other advanced procedures such as chemotherapy or organ transplant. Ongoing participation in C.E. courses: Ravenswood provides dentists and other team members time and C.E. allowance to encourage and provide opportunities for participation in learning new techniques. Transition of care within the organization: Ravenswood’s dental team is trained and equipped to manage the needs of patients with SHCN such that the transition from pediatric to general dentistry is seamless within the facility. Both general and pediatric dentists can care for patients with special needs and provide dental treatment, both in office and in the operating room. Facility design: The clinic design meets all AwDA standards to accommodate patients with special needs. However, certain other design considerations allow for smooth in-office care delivery. For example, the clinic color scheme is very inviting and warm and does not overpower the senses. The dental operatories can accommodate a wheelchair in the room if needed to provide dental treatment for patients in the wheelchair without the need to transfer patients. Scope of services: The clinic has pediatric and general dentists, dental assistants and hygienists on staff who are trained and comfortable providing dental treatment to the special needs population in an out-patient dental clinic setting. In addition, having specialists such as oral surgeons and endodontists on staff allows for fewer referrals and more treatment that can be completed in the clinic. The providers have hospital privileges that allow for care coordination and consultation to limit overall general

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anesthesia exposures for the patient. Asynchronous teledentistry model with integration at a medical therapy unit and special education programs in the county: Ravenswood has an asynchronous teledentistry model that utilizes dental hygienists in alternative practice who work primarily at preschool or community sites across the county and who work at the California Children’s Services’ medical therapy unit and a preschool for CSHCN. These specific locations provide for an early introduction to

Integrated electronic medical records [such as Epic/Wisdom] offer interoperable solutions with other health care entities.

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oral health services, care coordination and dental desensitization for CSHCN. Integrated electronic medical records that offer interoperable solutions with other health care entities: Recent transition to Epic/Wisdom not only allows medical-dental integration within Ravenswood but also makes communication among the providers easier. The combined record allows coordination with specialists and medical providers outside of the organization who use the same EHR. This is possible through a feature of the EHR known as “Care Everywhere.”

Barriers

While the clinic strives to achieve its mission and vision through a thoughtful design and care delivery model, the

following barriers remain to expanding services for its patients: ■ High patient volume: As an FQHC, Ravenswood serves the most medically underserved in the community. The dental needs of this patient population are high, and accommodating all patients who need the services is an ongoing challenge. ■ Limited OR time: Dentists at Ravenswood compete for OR time that is shared with other dentists, and there are often increased wait times to get patients in for services. ■ Reimbursement: The dental reimbursement model through DentiCal allows billing for procedures, and the reimbursement does not keep pace with the ever-rising cost of providing dental services. As an FQHC, Ravenswood’s reimbursement model is that of a fee for visit rather than a fee for service. The costs of providing dental care have climbed steadily every year and with the pandemic have skyrocketed. However, the reimbursement rates do not keep pace. To realize our mission to serve those with special needs, Ravenswood relies on philanthropy in addition to patient revenue.

Conclusion

While the definition of CYSHCN describes this population as needing multispecialty care, not all CYSHCN have the same medical and or dental needs. For example, a child with autism or other developmental delays may require dental desensitization visits to cope successfully with a dental appointment. However, someone with a hematology/oncology condition may require consultations to determine the best timing for care and medical parameters to deliver the care rather than desensitization. Therefore, this paper highlights the PCHH model JUNE 2 0 2 2

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in fostering a robust health care practice for all CYSHCN. It mentions ongoing national initiatives with a spotlight on the Ravenswood Family Health Center in the East Palo Alto area of San Mateo County, California, to reduce the gap between dental and primary care practice. Additionally, the paper identifies four areas — education, clinical practice, HIT and financing — to guide the planning and implementation of the PCHH to improve the overall quality of care for CYSHCN. Improved communication between dental and primary care providers with open doors to collaboration and integration can help diagnose and treat dental and other health conditions like diabetes and hypertension early in life. The gravity of barriers to implementing integrated practice underscores the current effort and momentum to change how dental care is delivered within a holistic framework. Therefore, it is imperative to break down the medical and dental educational silos and establish interprofessional education to improve oral health competencies among primary care providers and, among dental providers, competencies caring for CYSHCN. Full integration between medicine and dentistry requires the free flow of clinical information between the two disciplines, achieved best through an integrated EHR/EDR system. Finally, without changes to medical and dental insurance and reimbursement systems, medical-dental integration will be difficult to achieve for CYSHCN. n RE FEREN CE S 1. Simon L. Overcoming historical separation between oral and general health care: Interprofessional collaboration for promoting health equity. AMA J Ethics 2016 Sep 1;18(9):941–9. doi: 10.1001/journalofethics.2016.18.9.pf or1-1609. 2. Oral Health in America: Advances and Challenges. U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research. Bethesda, Md. National Institutes of Health; 202:790.

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3. Newacheck PW, Hughes DC, Hung Y-Y, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics 2000 Apr;105(4 Pt 2):989–97. 4. Iida H, Lewis C, Zhou C, Novak L, Grembowski D. Dental care needs, use and expenditures among U.S. children with and without special health care needs. J Am Dent Assoc 2010 Jan;141(1):79–88. doi: 10.14219/jada.archive.2010.0025. 5. Lewis CW. Dental care and children with special health care needs: A population-based perspective. Acad Pediatr Nov– Dec 2009;9(6):420–6. doi: 10.1016/j.acap.2009.09.005. 6. Lewis C, Robertson AS, Phelps S. Unmet dental care needs among children with special health care needs: Implications for the medical home. Pediatrics 2005 Sep;116(3):e426–31. doi: 10.1542/peds.2005-0390. 7. Fisher-Owens S, Gansky S, Platt L, Weintraub J, Soobader M-J, Bramlett M, et al. Influences on children’s oral health: A conceptual model. Pediatrics 2007 Sep;120(3):e510–20. doi: 10.1542/peds.2006-3084. 8. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. 9. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Washington, D.C.: The National Academies Press; 2011:296. Accessed Dec. 15, 2021. 10. Dorfer C, Benz C, Aida J, Campard G. The relationship of oral health with general health and NCDs: A brief review. Int Dent J 2017 Sep;67 Suppl 2:14–18. doi: 10.1111/ idj.12360. 11. Lin JL, Haren KV, Rigdon J, Saynina O, Song H, Buu MC, et al. Pneumonia prevention strategies for children with neurologic impairment. Pediatric 2019 Oct;144(4):e20190543. doi: 10.1542/peds.2019-0543. Epub 2019 Sep 19. 12. McManus BM, Chi D, Carle A. State Medicaid eligibility criteria and unmet preventive dental care need for CSHCN. Matern Child Health J 2016 Feb;20(2):456–65. doi: 10.1007/s10995-015-1843-6. 13. Centers for Disease Control and Prevention. Children and youth with special healthcare needs in emergencies. Accessed Dec. 18, 2021. 14. McPherson M, Arango P, Fox H, Lauver C, McManus M, Newacheck PW, et al. A new definition of children with special health care needs. Pediatrics 1998 Jul;102(1 Pt 1):137–40. doi: 10.1542/peds.102.1.137. 15. American Academy of Pediatric Dentistry. Definition of Special Health Care Needs. Accessed Oct. 5, 2021. 16. The Child and Adolescent Health Measurement Initiative. 2018-2019 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). 17. American Dental Association. Patients with special needs. Accessed Sept. 28, 2019. 18. Lebrun-Harris LA, Canto MT, Vodicka P, Mann MY, Kinsman SB. Oral health among children and youth with special health care needs. Pediatrics 2021 Aug;148(2):e2020025700. doi: 10.1542/peds.2020-025700. Epub 2021 Jul 21. 19. da Costa CC, Almeida ICS, da Costa Filho LC, Oshima HMS. Morphology evaluation of primary enamel exposed to antihistamine and fluoride dentifrice — an in vitro study. Gen Dent Jan–Feb 2006;54(1):21–7. 20. Cermak SA, Curtin C, Bandini LG. Food selectivity and sensory sensitivity in children with autism spectrum disorders. J Am Diet Assoc 2010 Feb;110(2):238–46.

doi: 10.1016/j.jada.2009.10.032. PMCID: PMC3601920. 21. Gandhi RP, Klein U. Autism spectrum disorders: An update on oral health management. J Evid Based Dent Pract 2014 Jun;14 Suppl:115–26. doi: 10.1016/j.jebdp.2014.03.002. Epub 2014 Mar 27. 22. Kral TVE, Eriksen WT, Souders MC, Pinto-Martin JA. Eating behaviors, diet quality and gastrointestinal symptoms in children with autism spectrum disorders: A brief review. J Pediatr Nurs Nov–Dec 2013;28(6):548–56. doi: 10.1016/j.pedn.2013.01.008. Epub 2013 Mar 24. 23. Owens PL, Manski RJ, Weiss AJ. Emergency department visits involving dental conditions, 2018 HCUP statistical brief #280. Rockville, Md.: Agency for Healthcare Research and Quality; 2021 Aug:18. 24. Taylor M. Improving access to dental services for individuals with developmental disabilities. Sacramento, Calif.: Legislative Analyst’s Office; 2018:40. 25. Houtrow AJ, Kim SE, Chen AY, Newacheck PW. Preventive health care for children with and without special health care needs. Pediatrics 2007 Apr;119(4):e821–8. doi:10.1542/ peds.2006-1896. PMCID: PMC2367154. 26. Association of Maternal and Child Health Programs and National Academy for State Health Policy. National Standards for Systems of Care for Children and Youth with Special Health Care Needs. Accessed Nov. 9, 2021. 27. Prasad M, Manjunath C, Murthy AK, Sampath A, Jaiswal S, Mohapatra A. Integration of oral health into primary health care: A systematic review. J Fam Med Prim Care 2019 Jun;8(6):1838–1845. doi: 10.4103/jfmpc.jfmpc_286_19. PMCID: PMC6618181. 28. DentaQuest. Medical-Dental Integration. Accessed Dec. 3, 2021. 29. DentaQuest. Reversible decay. Accessed Dec. 3, 2021. 30. U.S. Health Resources and Services. Administration standard framework for levels of integrated healthcare. Accessed Dec. 15, 2021. 31. Robinson LA, Krol DM. Interprofessional Education and Practice … Moving Toward Collaborative, Patient-Centered Care. J Calif Dent Assoc 2014 Sep;42(9):616–8. 32. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2021:306–24. 33. Goldberg R. Standards for Approval of Cleft Palate and Craniofacial Teams. American Cleft Palate-Craniofacial Association; 2019:5. 34. Harvard University Resource Library for the Integration of Oral Health and Medicine. Promising practices. Accessed Dec. 21, 2021. 35. McKernan SC, Kuthy RA, Reynolds JC, Tuggle L, García DT. Medical-dental integration in public health settings: An environmental scan. Iowa City, Iowa: University of Iowa Public Policy Center; 2018:39–40. 36. U.S. Department of Health and Human Services. Priming the pump of primary care. Accessed Dec. 23, 2021. 37. Insight Policy Research. Coming home: The patient-centered medical-dental home in primary care training. Accessed Dec. 23, 2021. 38. Nowak AJ, Casamassimo PS. The dental home: A primary care oral health concept. J Am Dent Assoc 2002 Jan;133(1):93–8. doi: 10.14219/jada.archive.2002.0027. 39. Damiano PC, Reynolds JC, McKernan SC, Mani S, Kuthy RA. The need for defining a patient-centered dental home model in the era of the Affordable Care Act. Iowa City, Iowa:

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University of Iowa Public Policy Center; 2015 Aug. Access Dec. 23, 2021. 40. World Health Organization. Framework for action on interprofessional education and collaborative practice. 2010. Accessed Dec. 19, 2021. 41. Palatta A, Cook BJ, Anderson EL, Valachovic RW. 20 Years beyond the crossroads: The path to interprofessional education at U.S. dental schools. J Dent Educ 2015 Aug;79(8):982–96. 42. Ferullo A, Silk H, Savageau JA. Teaching oral health in U.S. medical schools: Results of a national survey. Acad Med 2011 Feb;86(2):226–30. doi: 10.1097/ ACM.0b013e3182045a51. 43. Caspary G, Krol DM, Boulter S, Keels MA, Romano-Clarke G. Perceptions of oral health training and attitudes toward performing oral health screenings among graduating pediatric residents. Pediatrics 2008 Aug;122(2):e465–71. doi: 10.1542/peds.2007-3160. 44. Ramos-Gomez F, Kinsler JJ, Askaryar H, Verzemnieks I, Garell C. Evaluation of an interprofessional education program in pediatric dentistry, medicine and nursing. J Dent Educ 2021 Jul;85(7):1228–1237. doi: 10.1002/jdd.12578. Epub 2021 Mar 4. 45. Section On Oral Health. Maintaining and improving the oral health of young children. Pediatrics 2014 Dec;134(6):1224–9. doi: 10.1542/peds.2014-2984. 46. National Interprofessional Initiative on Oral Health. Oral health integration into whole person care. Accessed Dec. 24, 2021. 47. Penn Dental Medicine. Care center for persons with disabilities: Persons with disabilities presentation series. Accessed Dec. 24, 2021. 48. U.S. Department of Health and Human Services Health Resources and Services Administration. Integration of oral health and primary care practice. 2014:21. 49. Qualis Health. Oral health: An essential component of primary care. Washington, D.C.: Qualis Health; 2015: 67. 50. National Network for Oral Health Access. A user’s guide

for implementation of interprofessional oral health core clinical competencies: Results of a pilot project. 51. American Academy of Pediatrics. Oral Health Risk Assessment Tool. 52. Dooley D, Casamassimo P, Royston L, Nowak A, Frese W, Mathew T, et al. Caries risk assessment in the medical office; identifying common risk factors toward a more effective screening tool. Pediatrics 2018 Jan 1;141(1_ MeetingAbstract):598. 53. National Maternal and Child Oral Health Resource Center. Bright Futures Oral Health Pocket Guide. Accessed Dec. 19, 2021. 54. Chou R, Pappas M, Dana T, Selph S, Hart E, Fu RF, et al. Screening and interventions to prevent dental caries in children younger than 5 years: Updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA 2021 Dec 7;326(21):2179–2192. doi: 10.1001/ jama.2021.15658. 55. Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto R, Divaris K, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 2017 Sep 15;39(5):135–45. 56. Contreras V, Toro MJ, Elías-Boneta AR, Encarnación-Burgos A. Effectiveness of silver diamine fluoride in caries prevention and arrest: A systematic literature review. Gen Dent May–Jun 2017;65(3):22–9. PMCID: PMC5535266. 57. Bernstein RS, Johnston B, Mackay K, Sanders J. Implementation of a primary care physician-led cavity clinic using silver diamine fluoride. J Public Health Dent 2019 Sep;79(3):193–197. doi: 10.1111/jphd.12331. Epub 2019 Aug 6. 58. National Network for Oral Health Access (NNOHA). Integration of Oral Health and Primary Care Practice Integrated Models Survey Results: Embedded Dental Providers. 59. National Network for Oral Health Access. Electronic Medical And Dental Record Integration Options.

60. U.S. Department of Veterans Affairs. EHR modernization. Accessed Dec. 30, 2021. 61. HealthPartners Medical and dental: The case for bringing plans together. Accessed Dec. 31, 2021. 62. Mosen DM, Banegas MP, Dickerson JF, Fellows JL, Brooks NB, Pihlstrom DJ, et al. Examining the association of medicaldental integration with closure of medical care gaps among the elderly population. J Am Dent Assoc 2021 Apr;152(4):302– 308. doi: 10.1016/j.adaj.2020.12.010. 63. Byrappagari D, Jung Y, Chen K. Oral health care for patients with developmental disabilities: A survey of Michigan general dentists. Spec Care Dentist 2018 Sep;38(5):281– 290. doi: 10.1111/scd.12303. Epub 2018 Jun 26. 64. Salama FS, Kebriaei A, Durham T. Oral care for special needs patients: A survey of Nebraska general dentists. Pediatr Dent 2011 Sep–Oct;33(5):409–14. 65. Borchgrevink A, Snyder A, Gehshan S. Increasing Access to Dental Care in Medicaid: Does Raising Provider Rates Work? California HealthCare Foundation; 2008 Mar:6. 66. Chalmers NI, Compton RD. Children’s access to dental care affected by reimbursement rates, dentist density, and dentist participation in Medicaid. Am J Public Health 2017 Oct;107(10):1612–4. doi: 10.2105/AJPH.2017.303962. 67. Vujicic M, Buchmueller T, Klein R. Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Aff (Millwood) 2016 Dec 1;35(12):2176–2182. doi: 10.1377/hlthaff.2016.0800. 68. DHCS Medi-Cal Dental. Smile California. 69. Aetna Dental. Dental-Medical Integration Program. Accessed Dec. 21, 2021. 70. Cigna. Cigna Dental Oral Health Integration Program. Accessed Dec. 21, 2021. T HE CORRE S P ON DIN G AU T HOR , Karen Raju, BDS, MPH, DPH-Cert., can be reached at dr.karenraju13@gmail.com.

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anesthesia use C D A J O U R N A L , V O L 5 0 , Nº 6

C.E. Credit

Strategies To Reduce the Use of General Anesthesia for Children and Adolescents With Special Health Care Needs: Dental Desensitization and ‘Shorten the Line’ Models Jean Calvo, DDS, MPH; Paul Glassman DDS, MA, MBA; Tara Glavin, MA, BCBA; and Helen Mo, DMD, MS

abstract Background: Providing access to preventive and restorative dental care for children and adolescents with special health care needs (SHCN) is an imperative step in improving and maintaining their overall health. Often children and adolescents with SHCN receive referrals for dental treatment with sedation or general anesthesia. However, many children who are currently referred for dental treatment using general anesthesia could have dental care using less invasive, costly and risky methods with a series of strategies in the community and dental setting. Methods: The aim of this paper is to describe two models of reducing indications and referral for dental care with sedation and/or general anesthesia: a community-based comprehensive care system referred to as “shorten the line” and the use of desensitization in the dental setting. Results: The “shorten the line” strategy is a system involving dental hygienists, dental assistants, care coordinators and behavior support specialists deployed in community locations such as preschools, schools, residential facilities and day programs. The dental desensitization model described in this paper integrates the use of telehealth, previsit imagery, interprofessional care, systematic desensitization, dental office accommodations and home oral health practice. Conclusion: By implementing innovative models of care for patients with SHCN, it is possible to increase the completion of dental treatment for patients with SHCN in a community location or dental office rather than referring the patient for care with general anesthesia.

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Practical implications: Dentists can implement interventions and adapt the ways in which they provide dental care to patients with SHCN to increase access to routine dental care for this population and reduce the number of patients requiring dental treatment with general anesthesia. Keywords: Special health care needs, access to care, general anesthesia AUTHORS Jean Calvo, DDS, MPH, is an assistant clinical professor in the division of pediatric dentistry at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None reported.

Tara Glavin, MA, BCBA, is a board-certified behavior analyst at the UCSF Center for ASD & NDDs, department of psychiatry at the University of California, San Francisco. Conflict of Interest Disclosure: None reported.

Paul Glassman, DDS, MA, MBA, is a professor and associate dean for research and community engagement at the California Northstate University, College of Dental Medicine in Elk Grove, Calif. Conflict of Interest Disclosure: None reported.

Helen Mo, DMD, MS, is a volunteer assistant clinical professor, division of pediatric dentistry at the University of California, San Francisco. Conflict of Interest Disclosure: None reported.

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hildren with special health care needs (CSHCN) is a term found in federal and state statutes and is used for program eligibility, measurement and reporting purposes. One definition of this term is, “Those who have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions. They also require health and related services of a type or amount beyond that required by children generally.”1 This is a broad term that includes many types of conditions. Other overlapping and in some cases more specifically defined terms include ‘‘children with special needs,’’ ‘‘children with disabilities,’’ “children with developmental disabilities” and ‘‘children with complex conditions.’’2 The ideas discussed in this article can apply to children in any of these groups. Providing access to preventive and restorative dental care for CSHCN is an imperative step in improving and maintaining their overall health. Special health care needs (SHCN) in children and adolescents span a wide array of domains, including behavioral, congenital, developmental and systemic diseases and disorders.3 In California, an estimated 10% to 20% of individuals under age 21 have SHCN,4 which commonly stem from asthma, attention deficit disorder, developmental delay, anxiety and autism spectrum disorder.5 A known consequence in CSHCN is an increased risk of dental caries.6

Due to conditions such as cerebral palsy, autism spectrum disorder, congenital heart disease and trisomy 21, CSHCN have been shown to experience caries at a higher rate in both their primary and permanent dentition, compared with their non-SHCN peers.7 Disappointingly, despite the increased risk and prevalence of dental disease in the pediatric SHCN population, the utilization of preventive dental care in individuals with SHCN is lower than it is in those without SHCN.8 The behavioral and medical conditions of CSHCN require individualized approaches to providing preventive and restorative dental care in this population. CSHCN can receive dental care in a variety of settings, such as schools, dental offices and hospitals, and through different modalities, such as behavior guidance, sedation and general anesthesia. Many CSHCN receive referrals for dental treatment with sedation or general anesthesia. Furthermore, trends show that the use of general anesthesia for pediatric dental care is increasing.9 Indications for general anesthesia can include medical conditions that require dental care to be completed in a controlled setting: lengthy, surgical or advanced dental procedures, which a child could not be expected to tolerate, and behavioral indications, such as severe anxiety and lack of cooperation. Some medical conditions of those with SHCN pose extreme risk during invasive dental procedures and eliminate the ability to render care in a non-hospital setting. Rendering of dental

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care to those with SHCN in any setting will often require consultation with the patient’s medical provider prior to care. Completing dental treatment with general anesthesia offers many benefits, including the patient not being conscious during the procedure, thereby eliminating the need for patient cooperation, the dentist’s ability to complete more dental procedures at a time and the dentist’s ability to safely complete dental care in a controlled setting. However, general anesthesia also has associated risks, including mortality, and is the most medically invasive method of dental care.10 Additionally, it is the costliest method of delivering dental care.11 Furthermore, treatment of dental disease with general anesthesia in patients with SHCN is not a long-term solution to poor oral health, as CSHCN are likely to develop new caries following treatment and are likely to be treated multiple times with general anesthesia for dental care.12 As the use of general anesthesia for dental procedures is increasing, the proportion of children and adolescents with SHCN is large and only a limited number of providers can offer this type of specialized care. Hence, patients may have to wait several months or years in some areas to receive care with general anesthesia.13,14 As a result, many children experience pain and reduced quality of life while waiting for care. The decision to provide dental care with general anesthesia should always include an individualized comprehensive evaluation of the indications, risks, benefits and alternatives to providing dental care in this way — and only be recommended when less invasive, risky and costly methods are not possible.15 The aim of this paper is to describe two models of reducing indications and referral for dental care with sedation and/ or general anesthesia: a community-based

comprehensive care system referred to here as “shorten the line” and the use of desensitization in the dental setting.

Community-Based Comprehensive Care System (Shorten the Line)

Many CSHCN, particularly those with intellectual and developmental disabilities (IDD), are nervous in unfamiliar environments. In addition, some children with IDD have limitations in expressive language, which can be exacerbated at a time or in a location where they are nervous. A dental office or clinic is one

Treatment of dental disease with general anesthesia in patients with SHCN is not a long-term solution to poor oral health.

environment where such an individual may be anxious and may be unable to adequately express their concerns or feelings. They may not be responsive to attempts to have them enter the office, sit in the waiting room, sit in a dental chair or allow any examination of their mouth. Consequently, this individual may be labeled as “uncooperative” and referred for dental treatment using sedation or general anesthesia. However, this same individual may respond differently in a more familiar environment. Multiple decades of experience by some of the authors of this article have led to the conclusion that many children who are currently referred for dental treatment using general anesthesia could have dental care using less invasive, costly and risky methods with a series of strategies that are

initiated in community sites prior to any interactions in a dental office or clinic. The Special Care Dentistry Association published a consensus statement more than a decade ago about the use of sedation, anesthesia and alternative techniques for people with special needs.16 That consensus statement described a number of nonpharmacological strategies that can reduce the need for sedation and general anesthesia but are underutilized because of limited training in their use, reimbursement mechanisms and consequent lack of availability. These interventions and strategies include behavior support, physical support, psychological support, social support and prevention strategies. The College of Dental Medicine at California Northstate University (CNU), along with other partners, is developing a system to “shorten the line” to demonstrate the ability to reduce the number of individuals referred for dental treatment using general anesthesia. If some of the people currently referred for dental treatment using general anesthesia could have their dental needs met with nonpharmacological interventions and strategies, it could significantly reduce waiting times for those whose only option is general anesthesia. It would also lower costs to the health care system, reduce risk associated with pharmacological approaches and help “normalize” the experience of having dental care for these individuals. CNU is developing a communitybased comprehensive care system as part of the shorten-the-line strategy. The system involves using dental hygienists, dental assistants, care coordinators and behavior support specialists deployed in community locations such as preschools, schools, residential facilities and day programs. The activities of JUNE 2 0 2 2

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these individuals are integrated with the Regional Center System, which is California’s social service system for people with developmental disabilities.17 The primary strategies in the shortenthe-line system are described below. A system to identify individuals at risk of being referred for dental treatment using sedation or general anesthesia: Individuals at risk can include those with a previous history of dental care using general anesthesia, a history of difficulty with office-based general health or dental care or a history of anxiety in unfamiliar environments. Community-based behavioral, physical and psychological support: This includes an oral health team, including dental hygienists and assistants, working with care coordinators and behavior support specialists who are deployed in the community locations listed previously and perform behavior support interventions. These include desensitization and development of a behavior support plan and strategies. Minimally invasive communitydelivered diagnosis, prevention and early intervention strategies: These interventions use the concepts of the virtual dental home system where dentists who are not on-site are able to use store-andforward asynchronous teledentistry systems to review records and perform a comprehensive examination, diagnosis and treatment plan.18,19 The community team can perform traditional dental hygiene procedures, apply silver diamine fluoride and perform interim therapeutic restorations. In addition, they are trained to support the individual, parents and other caregivers in adopting “mouthhealthy habits,” the daily application of which is essential to good oral health. Targeted referral and support for dental offices: After the desensitization, prevention, early intervention procedures 348

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and adoption of “mouth-health habits” are underway, a “warm handoff” referral can be made to a prepared and receptive dental office. These “targeted referrals” include matching the patient’s needs and situation to the training and capacity of the dental office and providing information on the patient’s health, behavioral and social history and the procedures for obtaining consent to care. It also involves a “warm handoff” of the behavioral support plan so personnel in the office can continue and expand on the strategies that have been working in the community environment. These strategies are far more likely to result in a referral to a dental office that will lead to treatment in that office rather than a subsequent referral for dental care using general anesthesia.

Dental Desensitization To Increase Acceptance of Dental Care and Reduce Behavioral Indications for Dental Procedures With General Anesthesia

Every community may not have the support of a community-based comprehensive care shorten-the-line system. However, there are approaches that can be used that are centered at the dental office level that can also be beneficial in providing oral health services in an office environment rather than a referral for care using general anesthesia. These approaches include using telehealth for initial data gathering, pre-visit imagery and practice, use of behavior support professionals and office-based systematic desensitization. Systematic desensitization is the gradual exposure of individuals to a stimulus or setting that they may be hypersensitive to or that may induce anxiety. The goal of systematic desensitization is to increase an individual’s tolerance and acceptance

of a stimulus. Particularly, the pairing of relaxing or calm-inducing stimuli with the noxious stimulus can result in increased acceptance over time.20 CSHCN may exhibit behaviors related to anxiety of hypersensitivity in the dental setting. This behavior is an unmodulated nervous system response to the stimuli of the dental setting and can lead to behavior that the dental provider perceives as uncooperative. While the use of general anesthesia to treat this type of patient will remove the need for the patient’s cooperation, it does not allow the patient to build long-term skills or the ability to accept dental care — and it does not contribute to the prevention of future dental disease. Systematic dental desensitization has been shown to increase the acceptance of in-office dental routines among people with developmental disabilities — particularly those with neurodevelopmental disorders such as autism spectrum disorder (ASD), as this group of SHCN patients may have behavioral indications for dental treatment with general anesthesia without additional complex comorbidities. Dental desensitization is an evidencebased behavior support intervention that increases the acceptance of dental care among children.21 Furthermore, unlike treatment with general anesthesia, dental desensitization allows children to learn to accept dental visits over time.22 One model of dental desensitization used at the UCSF Pediatric Dental Clinic integrates the use of telehealth, pre-visit imagery, interprofessional care, systematic desensitization, dental office accommodations and home oral health practice.

Integrating Telehealth Consultations and Dental Desensitization An initial aspect of dental care for

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CSHCN is data gathering to understand the patients’ medical history and dental history. Furthermore, when implementing a dental desensitization approach, understanding the communication styles and behavioral needs of the patient is important. As physically being in the dental office can prove challenging to patients with SHCN, limiting the amount of non-treatment time spent in the dental setting can benefit them. The use of secure telehealth tools to meet with parents/guardians of CSHCN prior to an in-office visit can allow for comprehensive data gathering without exposing patients to the anxiety of the dental setting.23 At this initial telehealth consultation for parents/guardians of those with SHCN, UCSF Pediatric Dentistry gathers information on: ■ Medical history, including behavioral diagnosis. ■ Dental history, including oral hygiene practices. ■ Behavioral support services the child is receiving, such as applied behavior analysis (ABA), speech therapy, occupational therapy or physical therapy. ■ Education, including school level and type of classroom (integrated or special education). ■ Communication, including expressive language ability, receptive language ability, reading level and specific communication styles or tools used at home or school, if any, such as visual schedules, social stories, timers or picture exchange communication systems. ■ Sensitivities the child may have, especially in association with a dental setting, such as sensitivities to bright lights, sounds, tastes or smells. An important part of this initial consultation is asking the parent how their child’s last dental visit went and

how the parent feels the visit could have been improved. Additionally, this consultation gathers information on the best incentives and relaxing methods for the child. This initial telehealth consult allows the practitioner to gather information needed to see the patient, increases the practitioner’s preparedness for a successful dental visit and reduces the amount of time that the patient spends in the dental office. Patients who are able to and want to meet with the dental team via telehealth prior to their first in-office dental

Pre-visit imagery is an antecedent intervention that can be used prior to in-office desensitization.

visit are invited to join the telehealth visit. This provides the patient an opportunity to meet the dental team in a nonthreatening environment and become familiar with the providers prior to the actual appointment. This also enables patients to ask their own questions and express their concerns, thus allowing them to be an active participant in the conversation about their care.

Pre-Visit Imagery

Pre-visit imagery is an antecedent intervention that can be used prior to in-office desensitization.24 It allows individuals to start to gain exposure to the dental setting and dental care without having to be physically present in the dental setting or to actually undergo a procedure. Pre-visit imagery can include

pictures, social stories, videos and virtual dental office tours. UCSF Pediatric Dentistry has created a six-minute video that demonstrates a routine dental visit: the check-in process, the dental chair, personal protective equipment, a mouth mirror, an explorer, prophylaxis, an air/ water syringe, suction and the ending of the dental visit. Video modeling such as this has been shown to improve behavioral function for individuals with ASD.25 The UCSF dentist sends this video to the patient’s parent/guardian, with the request that the child watch the video at least once before their first clinical visit. With the advent of free and accessible video production through cellphones and websites, individual dental offices can easily make and share pre-visit videos to prepare their patients for in-office dental visits.

Interprofessional Care With Behavioral Therapists

UCSF Pediatric Dentistry works with a board-certified behavior analyst (BCBA) to design, implement and support desensitization plans for children with SHCN. While dentists may not have a BCBA or other behavioral health professional on-site, dentists can work interprofessionally with their patients’ behavioral therapists. If a SHCN patient is known to receive ABA therapy or have an occupational therapist, the dentist can discuss aspects of the dental visit with the ABA or occupational therapist and request that they help to prepare the patient for their upcoming dental visit during their therapy sessions. Furthermore, dentists can work with patients’ ABA or occupational therapists to help set goals for improvement and implementation of home oral hygiene practices, such as brushing and flossing.

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Systematic Desensitization

Following the initial telehealth consultation and pre-visit imagery, the patient presents to the dental clinic for their first desensitization visit. During the first dental visit, the goal is to determine the child’s comfort level and ability to complete a routine dental visit. Based on the individual’s behavioral needs during this first visit, the child may only enter the dental operatory or may complete the entire dental visit. The assessment of the patient’s comfort with and ability to complete a dental visit progresses from the patient’s ability to be in the dental chair to additional steps of a dental visit, such as examination, prophylaxis and completion of radiographs. During dental desensitization visits, the child is gradually exposed to each step of the goal dental procedure. If the child can be in the dental room comfortably, they are asked or indicated to sit in the dental chair; if this is comfortable for the child, the next steps are introduced to the child progressively. If at any point the child begins to show signs of anxiety, such as covering their eyes, ears or nose, moving away from the stimulus, crying or trying to escape, the stimulus is removed and a calming stimulus is introduced. Halting progress of the dental appointment and implementing behavioral supports at the initial signs of distress are more likely to allow the visit to continue successfully than waiting until the patient is highly distressed before pausing and addressing the behavioral need. The calming stimulus can be individualized for each child, but examples include watching videos on a tablet, playing with a fidget toy or listening to music. If the child appears to no longer be anxious, the last attempted step of the dental visit is reintroduced. The pattern of introducing a dental step, observing how the child responds and 350

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pairing a calming stimulus as needed is repeated. If the child cannot be calmed, the visit is terminated at that time. An appointment is then scheduled for the child in one to two months to reintroduce the anxiety-inducing step and attempt to progress through the remaining steps of the visit. Each patient has a different level of ability during the first visit, and goals are set for the next visit based on what has been accomplished thus far. Through repeated exposure to the dental setting and the steps leading up to a procedure, most children can learn tolerance and gain acceptance to complete an entire routine dental visit.21

Office Environment Accommodations for Desensitization Visits

Dental desensitization can happen in any dental office, however, making some accommodations to suit preferences and needs of patients can aid in the success of these visits. An initial accommodation made in the desensitization appointment is to eliminate or reduce time that the patient is in the waiting room or reception area. These settings can have many unfamiliar people, be highly active and be uncomfortable for individuals with ASD. At desensitization visits, the patient is greeted immediately in the waiting area and is not asked to sit in the waiting room. To further reduce distractions and overstimulation, desensitization visits are completed in dental operatories that are protected from the other clinical space, such as a “quiet room.” Additional accommodations for these desensitization visits include providing supports that meet the preferences of the patient. Patients who have sensory differences are offered sunglasses to protect their eyes, noise cancelling headphones and weighted blankets. Options are also provided to meet patient preferences such as a variety of toothpaste flavors

and manual or electric toothbrushes. Some patients also benefit from the use of calming sensory-related items/toys. For these patients at the desensitization visits, music may be played and a sensory toy box is offered with items such as fidget spinners, squishy balls and visually pleasing items like a liquid bubble timer. These items allow patients who prefer increased sensory stimulation to have an improved dental office experience.26

Home Oral Health Practice

Establishing a team with the parents and/or caregivers of children and adolescents with SHCNs is an essential element for successful desensitization in the dental environment. The parents and caregivers of these patients provide the majority of oral health care, and these home oral health practices are imperative in caries prevention. Furthermore, addressing caregiver burden and providing support to caregivers is important in improve the oral healthrelated quality of life for patients and their families.27 The role of dental and behavioral providers is to advise and support the caregivers of patients. A team approach incorporating the dental and behavioral providers, caregivers and patient enables preventive oral health practices and dental desensitization to be practiced and maintained outside of the dental office environment.28 Some steps of a dental visit that pertain to a goal the provider has set can be practiced at home. If the child finds a mouth mirror to be anxiety inducing, the provider can send a plastic mirror home with the parent/guardian to practice using with the child prior to their next dental visit. If the provider plans to apply silver diamine fluoride at a future visit, they can provide the parent/guardian with a microbrush and cotton rolls to mimic the procedure with

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the child at home. Home practice can facilitate increased desensitization for the patient without having to be in the dental setting.28 Dental providers can also work interprofessionally with a patient’s ABA therapist to describe specific goals of the next dental visit and encourage the patient to practice the corresponding steps outside of the dental setting.

Conclusion

The number of children referred for dental treatment using general anesthesia can be reduced using community-based strategies and interventions. These can result in a “warm handoff” of a behavior support plan and other information that can lead to treatment in that office rather than a subsequent referral for dental care using general anesthesia. Even in locations where communitybased interventions are not available, important strategies can be adopted in dental office environments. Through repeated short desensitization visits and gradual acceptance of aspects of the dental visit, children and adolescents can gain the skills necessary to complete a dental visit without restraint, sedation or anesthesia. Pairing this with early preventive dental care and improved diet and home oral hygiene can greatly reduce dental disease in CSHCN and increase their ability to complete dental visits, ultimately reducing the number of children referred for dental care with general anesthesia for solely behavioral reasons. n AC KN OW LEDGM EN TS The UCSF pediatric dentistry dental desensitization program is funded in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3.2 million with 0% percentage financed with nongovernmental sources. The contents are those of the authors and do not necessarily represent the official views of nor an endorsement by the HRSA, the HHS or the U.S. government. RE FEREN CE S 1. HRSA Maternal and Child Health. Improving the Lives of Children and Youth with Special Health Care Needs

(CYSHCN). Accessed Nov. 28, 2021. 2. Glassman P, Subar P. Improving and maintaining oral health for people with special needs. Dent Clin North Am 2008 Apr;52(2):447–61, viii. doi: 10.1016/j.cden.2007.11.002. 3. Council AO. Guideline on management of dental patients with special health care needs. Pediatr Dent Sep–Oct 2012;34(5):160–5. 4. Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children’s Health. As cited in Children with special health care needs: A profile of key issues in California. Lucile Packard Foundation for Children’s Health: Oct. 2010. 5. Van Dyck PC, Kogan MD, McPherson MG, Weissman GR, Newacheck PW. Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med 2004 Sep;158(9):884–90. doi: 10.1001/archpedi.158.9.884. 6. Guideline on caries-risk assessment and management for infants, children and adolescents. Pediatr Dent Sep–Oct 2013;35(5):E157–64. 7. Lebrun-Harris LA, Canto MT, Vodicka P, Mann MY, Kinsman SB. Oral health among children and youth with special health care needs. Pediatrics 2021 Aug;148(2):e2020025700. doi: 10.1542/peds.2020-025700. Epub 2021 Jul 21. 8. Craig MH, Scott JM, Slayton RL, Walker AL, Chi DL. Preventive dental care use for children with special health care needs in Washington’s Access to Baby and Child Dentistry program. J Am Dent Assoc 2019 Jan;150(1):42–48. doi: 10.1016/j.adaj.2018.08.026. Epub 2018 Oct 24. 9. Rudie MN, Milano MM, Roberts, MW, Divaris K. Trends and characteristics of pediatric dentistry patients treated under general anesthesia. J Clin Pediatr Dent 2018;42(4):303–306. doi: 10.17796/1053-4628-42.4.12. Epub 2018 May 11. 10. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth 2013 Aug;23(8):741–6. doi: 10.1111/pan.12210. Epub 2013 Jun 14. 11. Kanellis MJ, Damiano PC, Momany ET. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia. J Public Health Dent Winter 2000;60(1):28–32. 12. Guidry J, Bagher S, Felemban O, Rich A, Loo C. Reasons of repeat dental treatment under general anaesthesia: A retrospective study. Eur J Paediatr Dent 2017 Dec;18(4):313– 318. doi: 10.23804/ejpd.2017.18.04.09. 13. Lewis CW, Nowak AJ. Stretching the safety net too far: Waiting times for dental treatment. Pediatr Dent Jan-Feb 2002;24(1):6–10. 14. Keels MA, Vo A, Casamassimo PS, Litch CS, Wright R, eds. Denial of Access to Operating Room Time in Hospitals for Pediatric Dental Care. Chicago: Pediatric Oral Health Research and Policy Center, American Academy of Pediatric Dentistry; April, 2021. 15. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2020:292–310. 16. Glassman P, Caputo A, Dougherty N, Lyons R, Messieha Z, Miller C, Peltier B, Romer M. Special Care Dentistry Association consensus statement on sedation, anesthesia and alternative techniques for people with special needs. Spec Care Dentist Jan–Feb 2009;29(1):2–8; quiz 67–8. doi: 10.1111/j.17544505.2008.00055.x. 17. California Department of Developmental Disabilities. Regional Centers. Accessed Nov. 28, 2021.

18. California Northstate University College of Dental Medicine. The Virtual Dental Home System. Accessed Nov. 28, 2021. 19. California Northstate University College of Dental Medicine. The California Dental Transformation Initiative Local Dental Pilot Projects. Accessed Nov. 28, 2021. 20. Koegel RL, Openden D, Koegel LK. A systematic desensitization paradigm to treat hypersensitivity to auditory stimuli in children with autism in family contexts. Res Pract Persons Severe Disabil 29(2):122–134. doi.org/10.2511/ rpsd.29.2.122. 21. Nelson, T, Chim, A, Sheller, BL, McKinney CM, Scott JM. Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program. J Am Dent Assoc 2017 Jul;148(7):485–492. doi: 10.1016/j.adaj.2017.03.015. Epub 2017 Apr 19. 22. Yost Q, Nelson T, Sheller B, McKinney CM, Tressel W, Chim AN. Children with autism spectrum disorder can maintain dental skills: A two-year case review of desensitization treatment. Pediatr Dent 2019 Sep 15;41(5):397–403. 23. Cady R, Kelly A, Finkelstein S. Home telehealth for children with special health-care needs. J Telemed Telecare 2008;14(4):173–7. doi: 10.1258/jtt.2008.008042. 24. Fauziah E, Rachmawati S, Rachmadani AP, Susilo CW. Comparison of the educational effect of two and three dimensional books on dental anxiety in children with hearing impairment (aged 7–9 years). Indian J Public Health Res Dev 10(7):543. doi:10.5958/0976-5506.2019.01627.9. 25. Bellini S, Akullian J. A meta-analysis of video modeling and video self-modeling interventions for children and adolescents with autism spectrum disorders. Except Child 73(3):264–287. doi.org/10.1177/001440290707300301. 26. Kuhaneck HM, Chisholm EC. Improving dental visits for individuals with autism spectrum disorders through an understanding of sensory processing. Spec Care Dentist Nov–Dec 2012;32(6):229–33. doi: 10.1111/j.17544505.2012.00283.x. 27. Petrova EG, Hyman M, Estrella MRP, Inglehart MR. Children with special health care needs: Exploring the relationships between patients’ level of functioning, their oral health and caregivers’ oral health-related responses. Pediatr Dent May–Jun 2014;36(3):233–9. 28. Ferguson FS, Cinotti D. Home oral health practice: The foundation for desensitization and dental care for special needs. Dent Clin North Am 2009 Apr;53(2):375–87, xi. doi: 10.1016/j.cden.2008.12.009. T HE CORRE S P ON DIN G AU T HOR , Jean Calvo, DDS, MPH, can be reached at Jean.Calvo@ucsf.edu.

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C .E. CREDIT QUESTIONS

June 2022 Continuing Education Worksheet b.

This worksheet provides readers an opportunity to review C.E. questions for the article “Strategies To Reduce the Use of General Anesthesia for Children and Adolescents With Special Health Care Needs: Dental Desensitization and ‘Shorten the Line’ Models” before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please click here. This activity counts as 0.5 of Core C.E. 1. Which of the following statements concerning the use of general anesthesia to complete dental treatment for children with special health care needs (CSHCN) is not accurate: a. Eliminates the need for patient cooperation. b. Permits the dentist to complete more dental procedures at a time. c. Is the best solution to manage the child’s dental care needs. d. Is the costliest method for delivering dental care.

6. The UCSF Pediatric Dental Clinic model of dental desensitization uses which of the following strategies (mark all that apply): a. Telehealth b. Pre-visit imagery c. Interprofessional care d. Systematic desensitization e. Dental office accommodations f. Home oral health practice

2. T/F: The Special Care Dentistry Association’s Consensus Statement about the use of sedation, anesthesia and alternative techniques for people with special needs describes a number of nonpharmacological strategies that can reduce the need for sedation and general anesthesia; however, these techniques are underutilized because of limited training in their use, reimbursement mechanisms and lack of availability.

7. The benefit of the initial telehealth visit in the UCSF model includes all but which of the following: a. Facilitates comprehensive data gathering by the practitioner prior to an in-office visit. b. Allows the practitioner to assess the parent’s communication skills. c. Permits the practitioner to learn from the parent how their child’s last dental visit went and how the parent feels the visit could have been improved. d. Reduces the amount of time that the child spends in the dental office while not receiving treatment. e. Provides the patient an opportunity to meet the dental team in a nonthreatening environment.

3. The College of Dental Medicine at California Northstate University’s community-based “shorten the line” system includes all but which one of the following strategies: a. Identify individuals at risk of being referred for dental treatment using sedation or general anesthesia. b. Deliver behavioral, physical and psychological support using on-site community oral health teams. c. Provide diagnosis, prevention and early intervention strategies utilizing the virtual dental home care model and allied dental team members. d. Establish dentist rotations for on-site care. e. Use targeted referral and warm handoffs to dental offices. 4. T/F: The unmodulated nervous system response of a child with special health care needs to stimuli in a dental setting is often perceived as uncooperative behavior and often results in referral for general anesthesia. 5. Which of the following statements describe systematic desensitization: a. Systematic desensitization is the gradual exposure of individuals to a stimulus or setting that they may be hypersensitive to or that may induce anxiety. b. The goal of systematic desensitization is to increase the individual’s tolerance and acceptance of a stimulus. c. The pairing of relaxing or calm-inducing stimuli with the noxious stimulus can result in increased acceptance over time. d. Desensitization processes assist patients to build long-term skills that increase their ability to accept dental care. e. a, b and d f. All of the above.

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8. T/F: Though possible to do in a dental office setting, desensitization for CSHCN is difficult to do, so referral to a specialized program, such as those at UCSF or California Northstate University, is preferable. 9. Which of the following are used for desensitization visits (mark all that apply): a. Eliminate or reduce the time that the patient is in the waiting room or reception area. b. Complete the visit in a dental operatory that is protected from the other clinical spaces, such as a designated “quiet room.” c. Offer sunglasses, noise-canceling headphones and weighted blankets to individuals with sensory differences. d. Make available a variety of toothpaste flavors and manual or electric toothbrushes. e. Provide calming sensory-related experiences, such as playing music or offering fidget spinners or squishy balls, as appropriate to the child’s needs. 10. T/F: Pairing desensitization strategies with early preventive dental care and improved diet and home oral hygiene can greatly reduce dental disease in CSHCN and increase their ability to complete dental visits, ultimately reducing the number of children referred for dental care with general anesthesia solely for behavioral reasons.

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NYU Dentistry Oral Health Center for People With Disabilities Ronald W. Kosinski, DMD

abstract In February 2019, the NYU Dentistry Oral Health Center for People With Disabilities (OHCPD), an 8,000-square-foot center designed to provide dental care for people with physical, cognitive and developmental disabilities, opened its doors. The OHCPD provides much-needed comprehensive care for patients whose disabilities or medical conditions prevent them from receiving care in a conventional dental setting. Keywords: People with disabilities, vulnerable patients, training dentists

AUTHORS Ronald W. Kosinski, DMD, is the clinical director at the NYU Dentistry Oral Health Center for People With Disabilities and a clinical associate professor and director of pediatric sedation and anesthesia at the New York University College of Dentistry. Conflict of Interest Disclosure: None reported.

he purpose of this paper is to share the vision of the NYU Dentistry Oral Health Center for People With Disabilities and to encourage other dental schools to embrace this vision. NYU Dentistry has been committed to the goal of increasing access to oral health care for people with a range of disabilities for more than 50 years. Since 1971, the college has conducted a successful Special Patient Care Program, an honors program for a small group of exceptional dental students to gain experience caring for people with disabilities. About six years ago, the NYU Dentistry leadership made the decision to vastly expand the care offered to people with disabilities and the education and training provided for future practitioners, preparing them to provide compassionate, comprehensive oral health care for

these patients across the lifespan. This decision was motivated by an experience NYU Dean Charles N. Bertolami, DDS, DMedSc, had while preparing to cross East 24th Street in Manhattan, just outside the college’s main clinical building. Dr. Bertolami saw a disabled man in a wheelchair waiting for an Access-A-Ride van to pick him up, and he realized that the person’s disabilities were preventing him from holding his head steady. At that moment he became acutely aware that, “We can do better, we must do better.” Motivated by this vision, Dr. Bertolami wrote a white paper describing in detail the kind of treatment and educational facility he had in mind, and he asked Executive Vice Dean Michael O’Connor EdD, MPA, to explore the concept of an oral health center for people with disabilities that JUNE 2 0 2 2

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FIGURE 1. Oral Health Center for People With Disabilities main entrance.

FIGURE 2 . Expansive waiting room with noise-reduction baffled ceiling and a circular desk providing wheelchair accessibility.

FIGURE 3 . Longitudinal view of hallway showing entrances to nine treatment rooms.

FIGURE 4 . Treatment room showcasing wheelchair tipper made by Design Specific London.

would make his vision a reality. Dr. O’Connor assembled a team of about 30 people from various clinical 354

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areas who met weekly for approximately two years, during which they created a detailed plan to build a facility designed specifically for people whose disabilities or medical conditions prevented them from receiving care in a conventional dental setting. The team also visited a number of facilities in the northeastern United States that provide dental care for the disabled population. None of the facilities they visited offered the physical resources and the comprehensiveness and timeliness of care that reflected Dr. Bertolami’s vision. After completing this fact-finding phase of the project, the decision was made to create a facility that would go beyond what already existed — one that would incorporate the most advanced design and technology available to meet the specific needs of people with a full range of physical, cognitive, acquired and developmental disabilities. To that end, the college collaborated with a number of health care and advocacy groups that provide general health care and support for people with disabilities, including the Cerebral Palsy Associations of New York State, Metro Community Health Centers, Family Health Centers at NYU Langone, New York State Office for People with Disabilities, NYU Langone Health and the Viscardi Center. In addition, focus groups made up of people with disabilities were conducted in cooperation with the NYU Ability Project. An architectural firm that was able to implement all the unique design requirements for the center was hired, and the center was completed through a $12 million renovation and of an existing space. The NYU Dentistry Oral Health Center for People With Disabilities (OHCPD) opened in February 2019 (FIGURES 1 AND and 2 ). The 8,000-square-foot center addresses a major public health challenge by providing comprehensive,

compassionate dental care for people with a full range of disabilities who experience significant barriers to accessing care. Equally important, care at the center is ongoing with preventive continuity. By providing dental care across each patient’s lifespan, the center aims to break the vicious cycle of neglect and repeated hospitalizations.

The Need

According to the U.S. Census Bureau, in New York City alone, an estimated 950,000 people — in a city of 8.5 million — have some form of disability, and more than 99,000 of those people use wheelchairs. Research shows that people with disabilities have worse oral health than the general population and are less likely to have access to dental care.1 People with disabilities face many barriers to dental care, including physically accessing dental offices that which may not be able to accommodate wheelchairs or other assistive devices. In addition, some dentists lack confidence in their ability to meet the needs of people with disabilities, so they may not be prepared or willing to welcome disabled patients. As a result, patients with disabilities are often referred to hospitals for dental care because of the need for sedation, and they may wait as long as six months to get an appointment to be seen in a hospital OR. These visits are often one-off emergencies without follow-up or continuous preventive care, which can trigger a cycle of recurring dental problems.

Designed for People With Disabilities A major objective of the design process was to create an environment that felt both spacious and soothing and that flowed naturally from room to room as the accompanying photos illustrate. The center features nine spacious

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FIGURE 5 . The multisensory room, which showcases collaboration with other schools within NYU.

FIGURE 6 . Procedure room with bariatric treatment bench.

treatment rooms (FIGURE 3 ). In addition, there are two fully equipped sedation suites to provide both inhaled and intravenous sedation administered under the supervision of dental anesthesiologists. The center’s on-site sedation options are supported by integrated systems that include having the nitrous oxide pump located directly below the treatment center and enabling the production of restorations in a single visit. All of this ensures a high level of treatment comfort and safety not only for patients — the majority of whom no longer need to be referred to hospitals for procedures requiring sedation — but also for faculty providers and student doctors. Special accommodations for people

with disabilities include the following: ■ Wheelchair tilt: designed to accommodate patients receiving dental treatment in their own wheelchairs, without the need to transfer to a dental chair (FIGURE 4 ). ■ Multisensory room: designed to reduce patients’ agitation and anxiety, help them relax and engage their senses (FIGURE 5 ). Amenities include a bubble tube; noise-canceling headphones; soothing, adjustable, multicolored lighting; weighted blankets; body socks; and a projection screen. ■ Bariatric chairs: designed to accommodate patients up to 650 pounds (FIGURE 6 ). ■ Spacious, private treatment rooms: designed to offer privacy and comfort, with soothing, adjustable, multicolored lighting; noisecanceling headphones; and personal entertainment tablets (FIGURES 7 ). ■ Sedation: A nurse and a dental anesthesiologist conduct comprehensive exams to determine what level of sedation is most appropriate for a patient’s needs. The center is staffed by multidisciplinary faculty representing all the dental specialties, a clinical director, two dental anesthesiologists, a nurse, three patient services representatives, two dental supply assistants, four dental assistants, an assistant director and the director of oral health advocacy and policy initiatives. In addition, since Jan. 1, 2022, two dental hygiene students have been rotating through the center each week.

Training the Next Generation of Dentists Specializing in Treating People With Disabilities

In addition to offering much-needed clinical services to patients, the OHCPD provides a unique training opportunity for

NYU dental students, who will become the next generation of dentists with the skills to practice with competence, confidence and compassion in treating people with disabilities. To that end, students started full-day rotations at the center as soon as it opened. By investing in curriculum changes and in clinical rotations at the center, NYU Dentistry is educating students to embrace this patient population rather than resort to sending them to hospitals for care. Just as children are afraid of the unknown, dental students often have a fundamental fear of treating people with disabilities. One important way in which NYU Dentistry is training future dentists to care for those with disablities is by scheduling longer appointment times so that students have extra time to understand the patients’ needs from a medical and a psychological perspective in addition to the dental perspective. The increased appointment duration also allows students time to collaborate with faculty with experience and expertise in treating individuals with disabilities — helping students to learn how to integrate that specialized information into their approach to the patient. The biggest challenge was to create the right balance between care provided by dentists and care provided by students. Because of the complex needs of the majority of the center’s patients, the decision was made to have dental faculty from all the specialties, rather than students, provide care in complex cases. Accordingly, patients are cared for by faculty at the NYU College of Dentistry with particular interest and expertise in treating people with disabilities. Senior dental students provide basic dental care not requiring sedation and learn from the faculty providers. The results have been extraordinarily rewarding. Many of our providers JUNE 2 0 2 2

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FIGURE S 7. Treatment room that is approximately 330 square feet showing the ability to dim or change light color for sensory patients.

have noted that the experience of seeing patients who have been met with resistance their entire lives, who have never before had an X-ray taken or had anyone try to take an X-ray, or even look in their mouths, is an exhilarating one — for the patient, their family and the provider. The center is beginning to remove the roadblocks people with disabilities have encountered their entire lives.

Going Forward

When the OHCPD opened in February 2019, 10 to 15 patients a day were being seen. When the COVID-19 pandemic forced NYU Dentistry to suspend clinical operations on March 356

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13, 2020, the center was seeing 40 to 50 patients a day, ranging from newborns with recently diagnosed syndromes to the elderly, and was on target to provide 8,000 patient visits in 2020 and 10,000 visits in 2021. Although that trajectory was interrupted, the center was able to resume patient care in mid-July 2021. Since then, the center has been ramping up its services in a gradual, phased-in manner consistent with health and safety guidelines, and the faculty and students are optimistic about the future. Notably, the department of pediatric dentistry at the NYU College of Dentistry recently received a grant of nearly $2 million from the Health Resources and Services Administration (HRSA) toward training dentists and other dental care professionals to provide care for people with disabilities and complex medical conditions — a development that bodes well for advancing the goal of achieving health equity. And because NYU Dentistry is the largest dental school in the U.S., educating nearly 10% of the nation’s dentists, the prospects for having an exponential effect on the oral health needs of people with disabilities across the nation are extremely strong. In fact, we anticipate that, over time, many fewer people with disabilities will be referred to hospital ORs and many more will be treated in a conventional way.

Clinical Implications for Dentists

While having an innovative comprehensive clinic and suite for providing dental care to those with disabilities and complex medical conditions is not possible for every dentist, there are accommodations and modifications that can be made in traditional dental offices to support these patients.

Patient Scheduling

When scheduling a patient with disabilities or special health care needs, the appointment scheduler should ask the patient, parent and/or caregiver if there is an ideal time to schedule the appointment. Some patients may have medical conditions or daily routines that make an appointment at a specific time of day preferable. Furthermore, patients with developmental disabilities such as autism spectrum disorder often find the waiting room of a dental office uncomfortable and/or overstimulating. Scheduling patients with developmental disabilities in a way that ensures that the patient is immediately seen for treatment and does not spend time in a waiting area can increase the patient’s ability to tolerate the appointment.

Sensory Modifications and Accommodations

The dental office includes many sensory experiences that can be unfamiliar and displeasing to patients with developmental disabilities. The dental setting has bright lights, unusual tastes and loud noises in an unfamiliar setting. Some simple accommodations for the patient can help with the sensory discomfort that may lead to uncooperative behavior from these patients.

Sensory Modification Items and Music

Patients can be offered sensory modification items to enable them to better tolerate the dental setting. Simple interventions like sunglasses, noisecanceling headphones and dimming operatory lights can decrease the patient’s exposure to the bright lights and loud noises of the dental office. Furthermore, to make the dental office more acoustically tolerable for the dental patient, music that is calming or pleasing to the patient can be played during the dental visit.

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Toothpaste Options

Having multiple flavors of prophy paste and/or asking the patient to bring their preferred flavor of toothpaste from home can help to reduce the patient experiencing unfamiliar or displeasing tastes in the dental office. Additionally, for patients who have strong taste aversion, flavorless prophy paste and toothpaste can be used in the office and/or suggested for the patient to use at home. These modifications can make cleaning of teeth more tolerable for patients with restricted acceptance of new flavors.

need to attend and complete routine dental visits in a traditional dental office.

T HE AU T HOR , Ronald W. Kosinski, DMD, can be reached at rkosinski@nyu.edu.

Conclusion

As a pediatric dentist and dental anesthesiologist who has treated many disabled children, I have been extremely frustrated when I have been unable to provide care for my patients who have disabilities as they grew older. So, it makes me incredibly happy that NYU is offering lifelong access to comprehensive, compassionate dental care to people of all ages who have disabilities instead of

Tactile Distractions

Some patients will respond better in the dental setting when they have tactile input that is calming or pleasing to them. A weighted blanket can increase comfort for some patients in the dental chair. If a dental office does not have a weighted blanket, the use of a radiograph lead apron can be used in a similar manner to provide a calming pressure sensation to patients in the dental chair. Additional tactile distraction can also aid patients in tolerating care in the dental clinic. Items such as fidget spinners, squishy toys and stress balls can provide an item for the patient to hold and use to reduce anxiety during a dental visit.

Desensitization

The dental office can be initially unfamiliar and uncomfortable to a patient with developmental disabilities. However, gradual exposure over time to the sights, sounds, smells, tastes and overall “feel” of the dental clinic can transform it into a safe and tolerable space for these patients. Pairing of the above-described modifications and accommodations with multiple, short desensitization visits over time can be highly effective — enabling individuals with disabilities to gain the skills they

Some patients will respond better in the dental setting when they have tactile input that is calming or pleasing to them.

referring them to hospitals, and that NYU is training the next generation of dentists to be able to treat this population. It’s also immensely gratifying to know that what NYU is doing to implement this paradigm shift in providing dental care to people with disabilities has spurred other dental schools to create their own facilities for the treatment of individuals with disabilities. Indeed, former NYU Dentistry faculty members who are now deans of other dental schools have built or are in the process of building centers of their own. My hope is that their actions will be replicated across the nation. n RE FE RE N C E 1. Morgan JP, Minihan PM, Stark PC, et al. The oral health status of 4,732 adults with intellectual and developmental disabilities. J Am Dent Assoc 2012 Aug;143(8):838–46. doi: 10.14219/jada.archive.2012.0288. PMCID: PMC4527687. JUNE 2 0 2 2

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care coordination C D A J O U R N A L , V O L 5 0 , Nº 6

Care Coordination: A Valuable Adjunct To Dental Practice — Lessons Learned in a Public Health Setting Ellen Darius, RDH, MS, MPH; Huong Le, DDS, MA; Sridevi Ponnala, BDS,DDS, MBA; and Curtis Le, DMD

abstract Background: Children and youth with special health care needs (CYSHCN) face numerous barriers in accessing dental care including a lack of providers who are comfortable and competent in addressing their needs. Care coordination is an effective and financially viable tool to navigate the complexities of the health care system and match patients to providers with the appropriate training and facilities to treat their specific needs. Care coordinators have been shown to improve access, reduce barriers and decrease health care costs for CYSHCN. Objectives: To present results of a care coordination pilot in two federally qualified health centers that worked with community dental care coordinators (CDCCs) as part of the Healthy Teeth Healthy Communities (HTHC) project to determine if this model is financially sustainable and potentially beneficial to connecting CYSHCN to dental care. Methods: Several case studies were examined to determine the efficacy of the care coordination model with regard to improving oral health outcomes by decreasing barriers to care for CYSHCN. Data were analyzed from two federally qualified health centers that participated in the dental care coordination pilot. Results: The results illustrate a positive correlation between care coordination and patients’ ability to establish a dental home. The data also show a decrease in the number of no-shows for the patients supported by care coordinators. Conclusions: This pilot demonstrated that care coordination improves access and continuity of care for all patient populations. Additional research and funding should be afforded to further investigate care coordination programs as a bridge to better oral health care for CYSHN. Keywords: Special needs dentistry, community and public health dentistry, vulnerable patients, pediatric dentistry

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AUTHORS Ellen Darius, RDH, MS, MPH, received her BS and MS in dental hygiene from the University of California, San Francisco. She spent several years as a dental hygienist in private practice and served as assistant clinical professor at the UCSF School of Dentistry. She participated in several research studies and received her MPH from UC Berkeley. Conflict of Interest Disclosure: None reported. Huong Le, DDS, MA, is the chief dental officer at Asian Health Services (AHS). She is also a faculty member at the University of California, San Francisco, School of Dentistry, Western University College of Dental Medicine, Arizona School of Dentistry and Oral Health, University of the Pacific and California Northstate University College of Dental Medicine. Conflict of Interest Disclosure: None reported.

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Sridevi Ponnala, BDS, DDS, MBA, is the chief integration officer/EVP of the Tiburcio Vasquez Health Center. She also has a faculty appointment with the University of the Pacific, Arthur A. Dugoni School of Dentistry and the Chabot College dental hygiene program. Conflict of Interest Disclosure: None reported. Curtis Le, DMD, is a graduate of the Arizona School of Dentistry and Oral Health and AEGD residency program at the University of California, San Francisco, School of Dentistry, adjunct faculty of Western University School of Dental Medicine, an MPH candidate at A. T. Still University and a staff dentist at Bay Area Health Center. Conflict of Interest Disclosure: None reported.

hildren and youth with special health care needs (CYSHCN) have at least one chronic physical, developmental, behavioral or emotional condition that requires more than routine health and related services.1 These children and their families face myriad barriers to health care including inadequate or inconsistent access to pediatric specialists, the need to manage multiple providers in disparate care systems and the high financial burdens associated with complex care. Quality dental care may be particularly difficult to attain due to a lack of providers with adequate training or who can provide necessary accommodations or who are willing and able to spend the extra time to provide specialized care to this population. According to the American Academy of Pediatrics, “optimal outcomes for children and youth, especially those with special health care needs, [require] interfacing among multiple care systems and individuals … [thus,] coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care and improvement in the patient/family experience of care.”2 A study by Williams et al. describes the barriers to dental care access faced by patients with special health care needs (SHCN) in an affluent metropolitan community.3 This study delineates the difficulties faced by these patients in a community that should be financially and socially able to provide dental care to this population. The study’s surveys showed a severe shortage of providers who are comfortable and competent in addressing the complexities presented by the growing SHCN population. The polled families reported approximately

20% of the SHCN community are without a dentist. Access to care was even more impacted for those SHCN patients of lower socioeconomic status. Making dental care coordination available to CYSHCN is an effective and financially viable tool for helping their families navigate the complexities of the U.S. health care system. The October 2020 National Academy for State Health Policy (NASPH) Report refers to care coordination as “[a] core component of federal and state efforts to improve health outcomes, reduce caregiver and patient burden and decrease health care costs for children and adults with chronic and complex conditions.”4 In addition to the NASPH’s list of care coordination benefits, care coordinators can provide patient advocacy in a way that reduces the potential for patient distrust of providers. Patient-centered advocacy by care coordinators prevents complex patients most in need of care from avoiding care and being noncompliant with treatment recommendations. In addition, care coordinators are in a position to foster trust and empower the communities they serve by addressing commonly cited physical and social barriers to care such as language and cultural differences.5 Care coordination has existed for years in medical clinic settings. Yet, in dental care settings it is a relatively new concept. The limited data looking at dental care coordination point to positive social and financial outcomes. In 2005, Willamette Dental Group (WDG) in Oregon piloted a project to utilize dental care advocates (DCA) to take advantage of new Oregon Medicaid care coordination financial incentives. Although the results were only preliminary, WDG demonstrated a model of care coordination that could work in dentistry. In the closing remarks of their study, WDG leadership believed DCA to have practice improvement potential

C D A J O U R N A L , V O L 5 0 , Nº 6

through “motivational interviewing.” The DCAs “helped patients to understand and follow through with recommended prevention and treatment services, how to receive and properly use prescriptions and home care products, scheduling recall appointments and troubleshooting barriers the patients might face.” The pilot program concluded that DCAs can establish a “trusting and engaged relationship with the patient.”6 The DCAs were trained in additional skills such as motivational interviewing and understanding different medications and dental products so as to help answer patient questions and engage patients in oral health care. With care coordinators helping providers and patients to align expectations and expedite care, compliance rates go up, no-shows go down and financial benefits become realized as time and money are saved. This concept translates into value-based care, reducing costs for organizations and patients alike.

challenges which intensified the barriers of access to care.”7 The study concludes that strong care coordination and communication between dentists, caregivers and other providers are essential for positive outcomes. The authors emphasize that the current dental health care system has failed to meet the basic needs of the SHCN community. They conclude that the comfort and dignity of the patient are of paramount importance and would benefit greatly from the adoption of the care coordinator model.

CHWs facilitate appointment-making and compliance with treatment recommendations and increase show rates.

Community Health Workers

Perhaps the most important benefit of employing community health workers (CHWs) is their ability to match patients to providers or organizations with the appropriate training and facilities to treat the patient’s specific needs. This works particularly well for patients with SHCN because of the additional impact of education, transportation facilitation and appointment coordination using culturally sensitive, language-appropriate communications. In the article, “Dental Health in Persons With Disabilities,” Devinsky et al. state that “systemic and structural barriers limit dental health for individuals with [SHCN], who have poorer dental hygiene, higher rates of dental disorders and less access to oral care … that patients with SHCN struggled inordinately with accessibility, comorbidities and communication

Paul Glassman, DDS, MA, MBA, writes in another article in this issue of the CDA Journal that the “hassle factors” of dealing with the complexities of intaking and appropriately scheduling and appointing patients with SHCN prevent many dentists from considering providing care to people with SHCN. This can be reduced or eliminated by adopting the care coordination model. Care coordinators can provide a thorough medical and dental history as well a comprehensive explanation of a patient’s needs and required accommodations prior to the first appointment. This makes the initial visit more tolerable for both patient and provider and decreases the time needed for comprehensive care. CHWs play a critical role for CYSHCN, connecting them with

appropriate dental care while providing culturally and linguistically appropriate outreach, information, referrals, health education, emotional support and connection to tangible services such as accessible transportation to appointments. Job titles for CHWs differ between and even within health care systems where they may be variously termed “patient navigators,” “community health advisors” or “promotores de salud.” Witmer et al. describe CHWs as “community members who work almost exclusively in community settings and who serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate care.”8 The American Public Health Association defines CHWs as “frontline public health workers who are trusted community members and have an unusually close understanding of the community served.”9 Often, CHWs live and work within their targeted community and have existing connections with both community members and dental providers. This trusting relationship enables CHWs to serve as a critical link between health services, social services and the community, facilitating access to services and improving the quality and cultural competency of service delivery.10 CHWs are relatively inexpensive to train, making enhanced care coordination a scalable model for improved access to dental care for CYSHCN that can be adopted by individual practices or across entire health systems. CHWs facilitate appointment-making, compliance with treatment recommendations and increase show rates. By increasing preventive care for CYSHCN, they reduce the likelihood of emergency care and costs of expensive emergency room visits. Finally, hiring and training community members within marginalized communities to provide JUNE 2 0 2 2

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care coordination services for CYSHCN builds community strength through economic and social empowerment.

Healthy Teeth, Healthy Communities and Care Coordination

In 2017, the Alameda County Public Health Department implemented the Healthy Teeth, Healthy Communities (HTHC) pilot, a local dental pilot project of the Dental Transformation Initiative.11 The project timeline was four years (April 2017 to December 2020). The HTHC project was an interagency collaborative to implement a countywide dental health care coordination system to ensure that Medicaid-eligible children ages 0 to 20 in Alameda County receive dental care emphasizing prevention and continuity of care services necessary to ensure their long-term dental health. The program successfully linked more than 10,000 children and youth, some of whom were CYSHCN, to available dental care providers. The grant funded 26 culturally and linguistically sensitive CHWs, referred to as community dental care coordinators (CDCCs). The idea of using CDCCs to increase access to dental care for underserved populations was inspired by the work of the American Dental Association (ADA) community dental health coordinator program. In 2006, the ADA established the community dental health coordinator pilot program to address the barriers that prevent underserved rural, urban and American Indian communities from receiving regular dental care and enjoying optimal oral health.12 In the HTHC pilot, CDCCs were hired and trained to work in 14 networks throughout the county including Asian Health Services (AHS) and Tiburcio Vasquez Health Center (TVHC). The CDCCs’ primary responsibility was to work closely with families and providers to 362

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connect children to dental care and ensure they received follow-up appointments. CDCCs initiated first contact with the clients and enrolled them into the practice with their consent. They then set up the patients’ appointments with dental offices and accompanied patients to their first appointment. They also oversaw the continuation of care and assisted in making preventive care appointments for at least six months to a year later. The success of HTHC care coordination is seen at both AHS and TVHC, so much so that TVHC retained and

The CDCCs are recruited from the communities where they are expected to serve.

expanded the role of care coordination to all age groups. The CDCCs are recruited from the communities where they are expected to serve, and they receive a comprehensive eight-week training curriculum that emphasizes the importance of access to dental care as part of overall health. They are supported in connecting with peers and providers within the community where they serve this target population. Since implementation, CDCCs have conducted outreach activities, provided assistance in navigating the Medicaid dental program, educated families about oral health, scheduled appointments and maintained close relationships with dental providers.

Asian Health Services

Utilizing funds from the HTHC grant,

AHS hired two CDCCs, one who speaks Chinese and one who speaks Vietnamese, to serve its two largest patient groups. They attended various health fairs and reached out to community members who were eligible and who needed dental care. The CDCCs provided an overview of the HTHC program, patient education and, if parents consented, scheduled appointments for dental examination and continuing care visits as indicated. The coordinators handled registration in advance of appointments that saved significant time for the in-office checkin process. Prior to a child’s first dental visit, the CDCCs prepared the parents using patient education modules. Because families were prepared, the children knew what to expect upon arrival at the dental office including the clinic flow as well as procedures such as tooth counting, use of air and water and the associated noises. This created a tolerable and sometimes pleasurable first encounter. Care visits became shorter by approximately seven to 10 minutes per visit due to parents and patients being well prepared because most of their questions were answered prior to the encounter. Like many dental practices, AHS was severely impacted by the pandemic in 2020. Children were no longer seen regularly in person for various reasons, such as restrictive COVID-19 guidance on dental practices, reduction in services, parental fear of contracting COVID-19 and many others. Fortunately, the children were still connected with their dental home through telehealth. Teledentistry allowed families to stay in contact with their CDCCs who continued to encourage good oral hygiene habits and connect patients with providers as needed for clinical consults and interventions. Although the pandemic resulted in a significant reduction of in-person appointments and

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TABLE 1

Asian Health Services HTHC Data 2018-2020 Total number

2018

2019

2020

Total

Family contacts

814

1,850

142

2,806

Enrollment: total unique patients

474

451

985

SHCN patient enrollment

Scheduled appointments

616

1,693 (for all patients 2018-2019)

830 (including telehealth, for all patients)

3,139

28 (4.5%)

81 (4.7%)

11 (1.4%)

120 (3.8%)

Continuity of care: total unique patients

466

450

976 (99% including patients with SHCN)

Continuity of care: patients with SHCN (referral to hospital dentistry)

6 (1)

8 (3)

2 (1)

16 (5)

No-show (rate)

outreach activities, the care coordination for these children continued. Based on the HTHC annual report published in late 2021, the no-show rate for AHS HTHC-enrolled patients was lower than 5%, compared to an 8% no-show rate for the general patient population. This low no-show rate for the HTHC-enrolled children was primarily attributed to care coordination. A true benefit of the HTHC program was the fact that 985 children found a dental home. This is demonstrated by approximately 99% of the enrolled children returning for subsequent continuity of care visits. The recall rate for non-HTHC patients at the health center was only 90% during the same time period (TA BLE 1 ). Although the compensation for CDCCs is higher than that of an average front office staff, the number of new patients brought into the practice, the low noshow rate and the shorter time spent for each appointment has made care coordination financially sustainable. At AHS, the CYSHCN population enrolled in the HTHC was relatively small, approximately 2% of the entire patient population. After their initial visits, all children enrolled in HTHC remained in the clinic system for their

continuity of care. This was a result of the work that the care coordinators provided to the families. These patients were treated by three pediatric specialists on staff at the health center. Those who required hospital care were referred to the hospital dentistry program for treatment. The SHCN patients undoubtedly benefited due to the continuity of care that was provided, especially during the pandemic with its increased patient isolation and other challenges. The AHS clinic also implemented a drive-thru fluoride varnish program in May 2020. CDCCs helped with the telehealth and drive-thru fluoride varnish programs. The dental staff conducted oral health assessments and applied fluoride varnish as indicated while the children remained seated in their car. The program was particularly well received by parents of SHCN patients. One mother of a child with autism told our staff how happy she was that we implemented the drive-thru varnish program. Her son was able to receive the preventive services without challenges. He always had a difficult time coming into the office. Their visits typically ran longer because of the amount of time and resources needed to make him feel

comfortable. At the drive-thru, he could remain in his car seat, a place of comfort and safety for him. As a result, he was happy and cooperative with the provider. One CDCC said, “This month I came across a 2-year-old patient who had come back for her four-month fluoride appointment. At her first appointment, she was uncooperative from the moment she stepped into the waiting room, and her mother had to restrain her the entire time during her appointment. At this second appointment, she was enjoying herself in the waiting room and cheerfully greeted me. She and her mom recognized me and we had a nice chat, and her mom was very happy that her daughter was more comfortable with the clinic. It was an overall positive interaction.” Because of this positive experience, the mom asked if her son could also come to this clinic. The CDCCs became great ambassadors for the practice and provided added value to the dental program.

What Staff and Parents Said

“This month I came across a 2-year-old patient who had come back for her fourmonth fluoride appointment. At her first appointment, she was uncooperative from the moment she stepped into the waiting JUNE 2 0 2 2

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TABLE 2

Tiburcio Vasquez Health Center HTHC Data 2018-2020 Total number

2018

2019

2020

Total

Family contacts

814

1,850

142

3,777

Consent to enroll

511

406

418

1,335

Scheduled appointments

988

1,560

1,352

3,900

68 (7%)

73 (4.67%)

89 (6.6%)

230 (6%)

Continuity of care (unique patients)

315

992

764

2071

Patients with special needs

105

No-show (rate)

room, and her mother had to restrain her the entire time during her appointment. At this second appointment, she was enjoying herself in the waiting room and cheerfully greeted me. She and her mom recognized me, and we had a nice chat, and her mom was very happy that her daughter was more comfortable with the clinic. It was an overall positive interaction.” CDCC “I am very grateful for helping me find such timely appointments for my kids. Without your help, I would not even have known how to access care for my child. Thank you.” P.T. “I was completely unaware that I had to brush my daughter’s teeth because no one has ever told me or shown me how to do it. I wasn't told to do it by my pediatrician. So, I had never brushed her teeth before until now." Parent

Tiburcio Vasquez Health Center

TVHC hired two CDCCs through the HTHC pilot project. With the addition of these CDCCs, the TVHC’s dental program gradually saw an increase with enrollment and utilization of dental services for children ages 0 to 20. This was achieved through “in-reach” and outreach efforts by the CDCCs. Moreover, there was improvement in patients’ compliance with appointments and continuity of care. Care coordinators also enrolled CYSHCN and supported them to ensure accessible 364

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health care services met their needs. Evidence has shown the effectiveness of care coordinators and the lessons learned from using this model especially with CYSHCN who are covered by Medicaid.13 Some of the tangible outcomes were reduction in no-show rates and increased continuity of care for clients enrolled in the HTHC program and served by the CDDC compared to other patients in the same age group not enrolled in the program. When we compare the noshow data, there is approximately a 6% variance between the no-show rate in patients enrolled in HTHC compared to nonenrolled patients. The other significant outcomes were increased patient satisfaction and increased access to dental care for children ages 0 to 20 due to outreach conducted by CDCCs. Due to efforts of CDCCs, 1,335 children established a dental home with TVHC (TA BLE 2 ). This also includes CYSHN who account for about less than 3% of children enrolled in the program. Most of the children who were enrolled into the program were high risk and their dental care was managed by a pediatric dentist and general dentist. Some of the patients were referred to hospital dentistry that was coordinated with the support of CDCCs. Due to the impact of CDCCs on the work, TVHC added CDCCs to the budget after termination of the HTHC grant in

December 2020. It is very important to invest in the necessary infrastructure to see positive health outcomes. Building an effective health care infrastructure that meets the oral health needs of all Americans and integrates oral health care effectively into overall health is critical.14 The pandemic affected all dental programs, causing a disruption in dental services for many patients across the United States. However, the families working with CDCCs were comfortable coming in for their dental appointments due to the trust and relationship they had with their CDCC. Despite the pandemic, families who had high-risk children between ages 1 and 5 remained compliant with drive-thru dental visits and fluoride varnish applications.

What Parents Said

“As a parent of four children, I was helped by a care coordinator with coordinating dental appointments and educating my children on the importance of dental care. This has been extremely helpful for my family, as two of my children needed to see a specialist.” V.V. “The care coordinator is very friendly and helpful. This made a huge difference in my family and has taken away stress that I used to have about taking my special needs child to the dentist.” F.C.

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Conclusion

Currently, care coordination models are not supported or funded by public or private payers, and policy revision is needed. The families with CYSHCN often experience care gaps because they have to navigate complex health care systems. The support provided by care coordinators is critical to removing the pervasive barriers to care faced by these families. However, there is no systematic billing process or incentives associated with this important care coordinator role. Care coordination has a large impact on patient oral health outcomes due to the increase in patient engagement and appointment attendance. The data provided by the recent state-funded care coordination program show a decrease in the number of no-shows and an increase in treatment completion rates for the patients supported by care coordinators. The CHW position pays for itself by generating revenue with patient appointment compliance, supporting and empowering providers with managing patients’ complex needs, thereby improving a patient’s overall health. In the Alameda County dental clinics, care coordination begins when a care coordinator initiates contact with the client and enrolls them into the clinic with their consent. They then set up the patient’s appointments with dental offices and accompany patients to their first appointment. For six months to a year, the care coordinators oversee continuation of care and assistance in making preventive care appointments. The continued success of HTHC care coordination is seen at AHS and TVHC. In fact, at TVHC the care coordinators have not only been retained but their role and scope of care has expanded to all age groups. The initial expense of hiring care coordinators is compensated by the increased revenue and return on

investment from increased continuity of care and reduced no-show rates. Medi-Cal is transitioning to valuebased care focusing on more equitable, coordinated and whole-person care. The Department of Health Care Services is in the process of implementing the CalAIM dental initiative centered around pay-for-performance applied to preventive services, continuity of care and establishment of dental homes for MediCal patients.15 CalAIM incentives support the hiring of care coordinators who are key to achieving pay-for-performance measures such as increased patient engagement and improved oral health outcomes. The HTHC examples at AHS and TVHC as well as the other programs cited clearly demonstrate that care coordination improves access and health outcomes for all patient populations. This care coordination model needs further study especially for high-needs patient populations such as seniors and SHCN patients and their families. For the tangible financial and care benefits, private health care systems should consider providing reimbursement for dental care coordination for all patients, especially those with SHCN. As demonstrated in these pilot projects, this model can reduce costs to the system, reduce stress on families and ultimately improve health outcomes. Under its new CalAIM initiative, Medi-Cal has approved care coordination as a reimbursable service. It is our hope that in California, dental practices will increase their utilization of care coordinators in order to bring better care to SHCN patients. n

care access for patients with special needs in an affluent metropolitan community. Spec Care Dentist Jul–Aug 2015;35(4):190–6. doi: 10.1111/scd.12110. Epub 2015 Apr 19. 4. National Academy for State Health Policy. National Care Coordination Standards for Children and Youth with Special Health Care Needs. Oct. 2020. 5. Natale-Pereira A, Enard KR, Nevarez L, Jones LA. The Role of Patient Navigators in Eliminating Health Disparities. Cancer 2011 Aug;117(15 Suppl):3543–52. doi: 10.1002/ cncr.26264. 6. Kottek A, Hoeft K, White J, Simmons K, Mertz E. Implementing care coordination in a large dental care organization in the United States by upskilling front office personnel. Hum Resour Health 2021 Apr 7;19(1):48. doi: 10.1186/s12960-021-00593-0. PMCID: PMC8028788. 7. Devin O, Boyce D, Robbins M, Pressler M. Dental health in persons with disability. Epilepsy Behav 2020 Sep;110:107174. doi: 10.1016/j.yebeh.2020.107174. Epub 2020 Jun 9. 8. Witmer A, Seifer SD, Finocchio L, Leslie J, O’Neil EH. Community health workers: Integral members of the health care work force. Am J Public Health 1995 Aug;85(8 Pt 1):1055–8. doi: 10.2105/ajph.85.8_pt_1.1055. PMCID: PMC1615805. 9. National Academy for State Health Policy. State National Care Coordination Standards for Children and Youth with Special Health Care Needs. October 2020. 10. American Public Health Association. Community health workers. 11. Alameda County Public Health Department, Office of Dental Health. Alameda County’s Local Dental Pilot Program Healthy Teeth Healthy Communities 2017-2020, Final Report. March 2021. 12. American Dental Association. Community dental health coordinator program celebrates 15 years of bringing more people into oral health system. 13. Stewart KA, Bradley KWV, Zickafoose JS, Hildrich R, Ireys HT, Brown RS. Care coordination for children with special needs in Medicaid: Lessons from Medicare. Am J Manag Care 2018 Apr;24(4):197–202. PMID: 29668210. 14. U.S. Public Health Service, Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. 15. Safety Net Clinic Billing Instructions for CalAIM Dental Initiatives. T HE CORRE S P ON DIN G E DI TOR , Ellen Darius, RDH, MS, MPH, can be reached at Ellen.Darius@acgov.org.

RE FE RE N C E S 1. Lucile Packard Foundation for Children’s Health. 2. Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and familycentered care coordination: A framework for integrating care for children and youth across multiple systems. Pediatrics 2014 May;133(5):e1451–60. doi: 10.1542/peds.2014-0318. 3. Williams JJ, Spangler CC, Yusaf NK. Barriers to dental JUNE 2 0 2 2

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billing C D A J O U R N A L , V O L 5 0 , Nº 6

Billing for Extra Time Needed to Treat Individuals with Special Needs Allen Wong, DDS, and Ellen Darius, RDH, MS, MPH

AUTHORS Allen Wong, DDS, EdD, has taught postdoctoral general dentistry for over 35 years in AEGD programs in the Bay Area, is the director of the University of the Pacific, Arthur A. Dugoni School of Dentistry’s hospital dentistry program and was the director of the Highland Hospital restorative implant program. He has lectured nationally and internationally in the areas of special care dentistry, rotary endodontics, implant restorations and minimally invasive dentistry. Conflict of Interest Disclosure: None reported.

Ellen Darius, RDH, MS, MPH, received her BS and MS in dental hygiene from the University of California, San Francisco. She spent several years as a dental hygienist in private practice and served as assistant clinical professor at the UCSF School of Dentistry. She participated in several research studies and received her MPH from UC Berkeley. She is passionate about increasing access to dental care for individuals with disabilities. Conflict of Interest Disclosure: None reported.

he goal of health care is that it should be fair, respectful and inclusive for all individuals. The population of those with medical, physical, behavioral or developmental conditions is increasing in their lifespan and comorbidities. There are multiple barriers to accessing dental care for this population. When care is attained, it is often for severe dental needs requiring hospital dentistry. The obvious strategy to lessen costly outcomes is prevention. However, dental providers may be hesitant to provide preventive treatment to individuals with special needs because of the extra time required for these services. A new code, CDT Code D9920, was introduced that allows providers to be compensated for the extra time required to provide preventive care to this underserved population. While this billing code has been in effect for over two years, many dental providers are not using this code or are not being reimbursed because of insufficient documentation. If used correctly, this code provides a financial incentive of $140 up to four times per year. The purpose of this article is to offer guidance to practitioners as to how and when to use this code and

encourage providers to begin accepting individuals with special needs Code D9920 was established for “behavioral management” to help accommodate for the extra time necessary to properly treat patients with special needs. Behavior management, defined as a process by which dentists can help clients identify appropriate and inappropriate behavior, learn problem-solving strategies and develop impulse control, empathy and self-esteem, can be an effective alternative to costly and invasive procedures. When employed appropriately, behavior guidance results in more positive attitudes toward dentistry and lays the foundation for a lifetime of positive oral health experiences. Documentation must indicate specific techniques applied according to the individual client’s needs. This ensures that dental records include information on techniques that result in successful outcomes and aids providers in reproducing positive dental experiences for clients at future visits. With all billing codes, a concern for fraud is always present. Therefore, documentation of why extra time is needed is important along with a “billable” procedure. Code D9920 for behavior management allows usage of JUNE 2 0 2 2

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four times per year with a procedure code and documentation of post treatment. According to AB-316 MediCal: benefits: beneficiaries with special dental care needs: “That documentation shall include the medical diagnosis of a patient’s condition, a description of additional steps undertaken by the provider in their attempt to successfully treat the patient, and the reason for the need of additional time for a dental visit.”

Instructions for D9920 Use ■

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Behavior Modification (D9920) is only payable for clients with special needs requiring additional time for dental treatment. Behavior Modification (D9920) is not payable when sedation is used as a behavior modification modality. This code cannot be combined with the use of nitrous oxide, oral sedation or general anesthesia. In these cases, it can be used if a provider chooses not to bill for sedation. When properly used, D9920 allows for payments of $140 for up to four visits in a 12-month period. The code cannot be used alone; it must be used in conjunction with other services that are billable, even if it is just combined with fluoride varnish or radiographs. Written documentation for payment shall include documentation that the client has special needs that require additional time to complete treatment. Special needs clients are defined as those who have a physical, behavioral, developmental or emotional condition that prohibits them from adequately responding to a provider’s attempts to perform a dental visit. Documentation must include a medical diagnosis. This diagnosis does not need to be a formal JUNE 2 0 2 2

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written diagnosis from a medical provider. It can be confirmed by a parent or caregiver. Custom documentation must include the reason for the need of additional time for a dental visit. The patient’s diagnosis alone is not sufficient documentation, and these claims will be denied. For example, a provider should not indicate “extra time was needed because the client is autistic” or “extra time was needed because the client is in a wheelchair.” A more detailed description is necessary. For example, “the client experiences ataxic movements due to cerebral palsy, requiring extra time for adequate placement of the X-ray sensor,” or “due to partial paralysis of the neck, the client is unable to tilt their head back requiring extra time to adequately clean the maxillary arch.”

Bringing It All Together

The new code is applicable in conjunction with a “billable procedure(s)” in a clinical setting and not meant for solely “observation” or desensitization visits. Once cleanings and fillings are completed, there is a good opportunity to engage the patient in a “proactive prevention” program. One of the most important concepts in medicine and dentistry is an accurate diagnosis. Dentistry has been too focused on fixing problems versus preventing disease. With minimally invasive techniques such as silver diamine fluoride, partial caries removal concepts and remineralizing strategies, we can help reduce rates of active caries, the need for extensive dentistry and in some cases, reduce the need for hospital dentistry. Each procedure mentioned can be a “procedure” used with the behavior management code, if warranted.

Caries risk assessment along with periodontal risks should always be diagnosed, treated and monitored for progress or decline. We cannot treat what we do not diagnose. It is imperative to have an accurate caries risk assessment to help justify the additional need for more appointments to support a prevention-based program and help improve the patient’s health. In doing so, we can avoid premature and unnecessary extractions and improve quality of health and life. Having less teeth to function can create a domino effect toward eating efficiency, gastrointestinal problems, social stigma and self-esteem. Along with a documented medical necessity, it also makes sense that there is a documented dental necessity. If properly documented, additional appointment intervals should be considered for which use of the D9920 code might not only be justified but appropriate. Being fairly compensated for the additional time taken to treat patients who need who need behavioral support while receiving their needed and preventive treatment is truly an inclusive concept. If dental providers who accept clients enrolled in MediCal can successfully bill for behavioral management, it will increase access to care for individuals with special needs. Individuals with special needs face numerous barriers in obtaining dental care. The lack of preventive care often results in severe dental needs requiring hospital dentistry. Providers may be hesitant to accept these clients because of the extra time required for their treatment. Including behavior modification and guidance techniques to your dental treatments can help individuals with special needs tolerate treatment and form positive dental experiences. The behavior modification

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code D9920 provides financial support for dentists to take the time necessary to provide this critical service. Readers can read the actual wording for the AB-316 Medi-Cal benefit here. n TH E CO RRE S P O NDIN G AU T H O R , Allen Wong, DDS, can be reached at awong@pacific.edu.

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RM Matters

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Patient Dismissals: Why, When and How TDIC Risk Management Staff

ust as the doo-wop song proclaims, breaking up is hard to do. When you must sever the patient-provider relationship, however, you must first thoughtfully consider potential risk and act in accordance with ethical standards of treatment. In addition to state laws and any Dental Practice Act requirements, ADA’s Code of Ethics can guide your decision. Your local dental association should offer guidance on the laws regarding treatment within your state. California Dental Association members also have access to a legal reference guide that includes helpful considerations for terminating doctor-patient relationships as well as specialized expertise through The Dentists Insurance Company’s Risk Management Advice Line. TDIC receives numerous calls regarding when the dentist should consider dismissing, for one reason or another, patients who are in active treatment. Recent calls to the Advice Line showcase the unique complexities of dismissing patients prior to completion of treatment.

Case Study: A Noncompliant Orthodontic Patient

Advice Line analysts received a call from an orthodontist regarding a minor patient who was noncompliant with treatment recommendations. The patient was breaking brackets by eating hard foods, failing multiple appointments and otherwise showing up late. The patient’s noncompliance had already caused significant treatment delays. The orthodontist felt the best approach would be to call the patient’s

parents into the office to discuss these concerns and determine if the case could get back on track or if treatment should be discontinued. Upon her arrival at the next appointment, the patient’s mother was asked to wear a mask while in the office in alignment with COVID-19 protocols. The mother became confrontational and refused to comply, stating she would never wear a mask while in the office. The orthodontist attempted to explain the rationale for the requirement,

but the mother’s position remained unchanged. Rather than press the matter further, the orthodontist advised the mother she would need to leave if she refused to comply with the mask mandate but agreed to contact her to discuss the matter later that day by phone. She reluctantly agreed to this compromise, but when the phone call took place that evening, the mother was less than pleasant. Despite the communication challenges, the treating

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orthodontist explained that when the patient was inconsistent with appointments and noncompliant, treatment could be delayed. The mother refused to accept responsibility for the delay in her son’s case and instead attributed the delay to the office closure during the pandemic. The orthodontist realized that he was at risk of losing his composure, so he ended the call and simply requested that they please keep all future appointments and be on time. He also provided a reminder about the acceptable foods to eat to avoid bracket breakage. During their phone conversation, the orthodontist avoided revisiting the mother’s failure to comply with the state mandate for wearing a mask during office visits. The patient was on time when he presented to the next appointment, however, the mother again refused to wear a mask. The office manager informed her that wearing a mask was not optional and asked the parent to wait outside during her son’s appointment. The mother hesitantly left and waited in her car. However, on her way out, she became more combative by slamming the door and shouting profanities directed at the dentist and staff. After reviewing the case, the Risk Management analyst advised the orthodontist that he should consider patient dismissal. Even though the patient was still receiving treatment, there were adequate grounds for dismissal due to the patient’s noncompliance and the parent’s escalating abrasive treatment. The analyst reminded the orthodontist to fully document the interactions with the mother in the patient file. They also guided the orthodontist in composing a letter to the patient providing a 30-day notice of dismissal, which allowed reasonable time for the patient’s 372

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parents to find a new orthodontist.

Case Study: A Demand for Refund or Refinement Another call received by TDIC’s Advice Line involved an adult patient nearing the completion of Invisalign treatment. The orthodontist felt the treatment was going well up to that point, but when the orthodontist was ready to deliver the retainer, the patient complained about the case outcome. Growing increasingly hostile and rude when communicating with staff, the

When dismissing a patient, provide a formal written notice stating that you are withdrawing care and requiring the patient to find another provider. patient demanded additional refinements and, if her demands weren’t met, a full refund of the treatment fee of $7,000. After the orthodontist reviewed the patient’s account with the front office, it became apparent that payment had not been made to the account in more than a year. When the orthodontist informed the patient of the past-due balance on the account and lack of recent payments, the patient argued that she had previously paid the balance of her account in full. There had been some changes to the front office staff during the patient’s treatment, and she claimed she had given a large cash payment to a staff member who was no longer employed there. The staff inquired if she had a receipt documenting this large payment, and the patient stated that she would try to locate it. The

patient argued that the office’s failure to ask her for payment over the past year or mentioning a balance due on her account was further proof that her account had been paid in full. The orthodontist and office staff did not have a satisfactory answer as to why the patient was allowed to go for an extended amount of time without being asked for a payment. When asked by the Risk Management analyst if a collections protocol was in place, the orthodontist explained that their office typically set the patients up with payment plans. The analyst explained that if the patient was unable to present a receipt and the orthodontist was unable to prove without a doubt that a cash payment had not been paid, then it would be best to consider the patient’s request for refinement. He was advised to focus on treatment completion in the meantime until the patient was able to provide a receipt for the cash payment, as refunding the $7,000 without proof it had ever been paid to the office appeared to be an unreasonable expectation

To Dismiss or Not To Dismiss?

Unsure whether to pursue dismissal? Some common and acceptable indicators that a dentist may need to consider dismissing a patient from care are: ■ The patient is noncompliant with treatment recommendations or attempts to dictate treatment. ■ The patient tries to take dental care into their own hands through actions such as attempting to make adjustments to a prosthesis or orthodontic appliance. ■ The patient has not been in for an extended amount of time. Consider dismissal if the patient has not been seen in 24 months. ■ The patient demonstrates abrasive behavior or makes inappropriate comments to the

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dental team or other patients. Patients may not be dismissed or discriminated against based on limited English proficiency or status within a protected category under federal or state legislation, including race, color, national origin, sex, disability and age. When dismissing a patient, provide a formal written notice stating that you are withdrawing care and requiring the patient to find another provider. Mail the confidential written notice to the patient by both first-class and certified mail with a return receipt requested. Risk Management analysts can provide guidance on the dismissal process and letters along with resources to protect dentists before finalizing the separation.

case selection, thorough or complete documentation and clear communication are essential to minimizing your risks. The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members and policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance.com/RMconsult or call 877.269.8844.

Patients in Midtreatment

In situations where orthodontic patients elect to discontinue treatment and establish care elsewhere or there is a behavioral problem with a patient midtreatment, automatic dismissal is not recommended. Allowing the patient to remain in appliances without ensuring the patient will be monitored could expose you to liability risks, such as patient abandonment. Furthermore, there is potential for the patient to increase the likelihood of relapse, broken brackets, loose wires, decay, decalcification, etc. If the patient dismisses themselves or if the dismissal is a last resort due to nonpayment, then the treating orthodontist should offer to remove the appliances and provide a retainer to maintain existing tooth positions and any orthodontic tooth movement achieved if appropriate. If you have questions or concerns about a possible dismissal, seek guidance before moving forward. CDA members benefit from access to TDIC’s Risk Management Advice Line at no cost. Remember that careful patient JUNE 2 0 2 2

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Regulatory Compliance

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OCR Cybersecurity Newsletter: Securing Your Legacy (System Security) U.S. Department of Health and Human Services October is Cyber Security Awareness Month and now is a great time for organizations to revisit the protections they have in place for their legacy systems. Health care organizations rely on many technical systems to deliver their services. The HIPAA Security Rule1 requires covered entities and their business associates to implement safeguards that reasonably and appropriately secure the electronic protected health information (ePHI) that these organizations create, receive, maintain or transmit. As health care entities’ technological footprint grows, the number of systems these organizations need to identify, assess and maintain grows as well. Many health care organizations rely on legacy systems, which is a term for an information system with one or more components that have been supplanted by newer technology and for which the manufacturer is no longer offering support. But despite their common use, the unique security considerations applicable to legacy systems in an organization’s IT environment are often overlooked. Ideally, all organizations would only use information systems that are fully patched and up to date. However, in reality, health care organizations must balance competing priorities and obligations. There are many reasons why a health care organization may elect to keep using a legacy system, such as: ■ The organization may not be able to replace the legacy system without sacrificing availability of data, disrupting critical services or compromising data integrity.

■

For health care providers, this can apply to medical devices, electronic health records and other systems offering critical services. The organization is reluctant to tinker with technology that appears to be working or to deploy a new and unfamiliar system that may reduce efficiency or lead to increased user errors.

■

The organization is reluctant to replace a system that is well-tailored to its business model or with which it has a high degree of competence. The organization’s other systems depend on the legacy system or are incompatible with newer systems. The organization is unable to dedicate the time, funds or human resources needed to retire and

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replace the legacy system. While many factors may contribute to an organization’s decision to continue to use a legacy system, it is important that the organization include security in its considerations, especially when the legacy system could be used to access, store, create, maintain, receive or transmit ePHI.

Managing the Security Risk of Legacy Systems

Legacy systems’ lack of vendor support makes them particularly vulnerable to cyberattacks. The HIPAA Security Rule requires covered entities and their business associates to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity and availability of ePHI throughout their environment, including ePHI used by legacy systems.2 An accurate and up-to-date asset inventory is a useful first step because it can help organizations understand where critical processes, data and legacy systems reside within their organization.3 After assessing the potential risks and vulnerabilities to their ePHI, covered entities and business associates must implement security measures to reduce those risks and vulnerabilities to a reasonable and appropriate level as part of their risk management.4 For legacy systems, this means identifying the potential risks and vulnerabilities to ePHI posed by those systems, the security measures the organization will take to reduce those potential risks and vulnerabilities and the proposed timeline, including (if possible) the legacy system’s ultimate retirement date. Organizations often elect one or more of the following strategies to mitigate a legacy system’s security risk: ■ Upgrade to a supported version or system. ■ Contract with the vendor or a third party for extended system 376

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support or migrate the system to a supported cloud-based solution. ■ Remove or segregate the legacy system from the internet or from the organization’s network. ■ Maintain the legacy system, but strengthen existing controls or implement compensating controls. If an organization elects to maintain a legacy system and strengthen its existing controls or implement compensating controls, those controls should be tailored to the potential risks and vulnerabilities identified with the legacy system. Such controls may include: ■ Enhancing system activity reviews and audit logging to detect unauthorized activity, with special attention paid to security configurations, authentication events and access to ePHI.5 ■ Restricting access to the legacy system to a reduced number of users.6 ■ Strengthening authentication requirements and access controls.7 ■ Restricting the legacy system from performing functions or operations that are not strictly necessary (e.g., by removing or disabling unnecessary software and services). ■ Ensuring that the legacy system is backed-up — especially if strengthened or compensating controls impact prior backup solutions.8 ■ Developing contingency plans that contemplate a higher likelihood of failure, especially if the legacy system is providing a critical service.9 ■ Implementing aggressive firewall rules. ■ Implementing supported anti-malware solutions. In addition to implementing safeguards required by the HIPAA Security Rule, covered entities and business associates are also required to review and modify their security measures to ensure the continued

protection of their ePHI.10 When a system is nearing legacy status (or is already a legacy system), organizations should assess the specific security risks associated with those systems. If an organization elects to maintain a legacy system, it should review and modify its security measures to ensure the continued protection of its ePHI. Finally, organizations should consider when the burdens of maintaining a legacy system will outweigh its benefits and plan for the legacy system’s eventual removal and replacement. n A DDI T ION A L RE SOU RC E S NIST Special Publication 800-70 Revision 4: National Checklist Program for IT Products – Guidelines for Checklist Users and Developers. NIST Special Publication 1800-8: Securing Wireless Infusion Pumps in Healthcare Delivery Organizations. NIST Special Publication 1800-24: Securing Picture Archiving and Communication System (PACS). Health Care Industry Cybersecurity Task Force, Report on Improving Cybersecurity in the Healthcare Industry 2017.

(This document is not a final agency action, does not legally bind persons or entities outside the federal government and may be rescinded or modified in the department’s discretion.) RE F E RE N C E S 1. OCR administers and enforces the HIPAA Privacy, Breach Notification and Security Rules at 45 CFR Part 160 and Part 164 Subparts A, C, D and E. The Security Rule establishes national standards to protect electronic PHI (ePHI) created, received, used or maintained by covered entities and their business associates. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity and availability of ePHI. 2. See 45 CFR 164.308(a)(1)(ii)(A): Risk Analysis. 3. See OCR Cybersecurity newsletter on maintaining an asset inventory. 4. See 45 CFR 164.308(a)(1)(ii)(B): Risk Management. 5. See 45 CFR 164.312(b): Audit Controls; 45 CFR 164.308(a)(1)(ii)(D): Information System Activity Review. 6. See 45 CFR 164.308(a)(4)(i): Information Access Management. 7. See 45 CFR 164.312(a)(1): Access Control; 45 CFR 164.312(d): Person or Entity Authentication. 8. See 45 CFR 164.308(a)(7)(ii)(A): Data Backup Plan. 9. See 45 CFR 164.308(a)(7)(i): Contingency Plan. 10. See 45 CFR 164.306(e): Maintenance.

See HIPAA FAQs for additional guidance on health information privacy topics. Reprinted with permission from the HHS Office for Civil Rights. Review previous newsletters and sign up here to have the quarterly OCR Cyber Awareness Newsletter sent to your email.

Tech Trends

C D A J O U R N A L , V O L 5 0 , Nº 6

A look into the latest dental and general technology on the market

Brave (Free, Brave)

iPrescribe (Free with purchase of DrFirst subscription)

Users have many choices when it comes to web browsers on mobile devices. Several factors should be considered, beyond simple preference, when comparing web browsers. Privacy and performance are among the most requested features in this tool that is used every day to surf the internet. Brave is a free mobile browser for iOS and Android devices that focuses on these features to provide a safe and optimized web experience for users.

As of Jan. 1, 2022, all prescriptions in California must be issued electronically. This law has given rise to a host of e-prescription services, of which DrFirst is among the largest. In 2018, DrFirst unveiled iPrescribe, a mobile app that allows users to prescribe, check prescription drug monitoring programs (PDMPs) and pass limited information to and from their electronic health records (EHR). Free with an active subscription to DrFirst, iPrescribe — available on Android and iOS — aims to help providers quickly, easily and securely provide medications to their patients while maintaining compliance with California law.

The premise for Brave is to protect users from cross-site trackers that are embedded in many websites for analytics and targeted advertising automatically in the background. The blocking of these trackers and ads from loading would directly save the transfer of data and indirectly speed up web browsing while saving time. New page tabs prominently display the number of trackers and ads blocked and data and time saved at the top. Brave Search is the default private search engine and does not track user searches or clicks. Most common web browser features are included as well as preference and data synchronization across Brave mobile and desktop apps. Some features are unique to this web browser, such as the ability to save a playlist of any video or stream for offline playback. Other specific features include Brave News, which is ad-supported news from customizable sources that are unobtrusively displayed as cards from a new tab page, and Brave Rewards, which incentivizes users with Basic Attention Tokens (BATs) for viewing tracker-free private ads that do not invade privacy. BATs can be exchanged for gift cards or treated like crypto currency and stored and managed from Brave Wallet, a secure crypto wallet that is built into the web browser. These specific features are not enabled by default, so users can enjoy a complete private browsing experience without having to opt in to features they do not need. Users can upgrade to a Brave Firewall + VPN service or host private video calls with Brave Talk Premium to extend their privacy beyond the web browser. The performance of this full-featured browser is robust and effective in blocking many ads and trackers across popular websites.

Upon successful setup of DrFirst, users will have accounts created for use with iPrescribe. Users can query a patient list from patients they have accessed in DrFirst on their EHR. This means that a provider’s entire patient pool may not be available to them on iPrescribe, so those using the app as the primary way of prescribing may encounter difficulties. iPrescribe’s interface is as advertised: simple and easy to use. Five options are available on the home screen — New Rx, Pending Rx, Renewals, Secure Chat and PDMP. From here, users can manage basic prescription writing tasks and receive on-demand help at any time. Integration with CURES (California’s PDMP) is straightforward to set up and use, with regular management of CURES credentials the only hurdle. If users understand that their entire patient population may not be available to them and that iPrescribe does not allow users to add patients, it is a valuable, timesaving tool for DrFirst users. — Alexander Lee, DMD

Privacy and performance are key features to have in web browsers on mobile devices. Brave provides an optimal web experience with additional premium options for users who value these features in a mobile browser today. — Hubert Chan, DDS JUNE 2 0 2 2

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Journa C A L I F O R N I A

D E N TA L

A S S O C I AT I O N

CDA Journal-JUNE 2022: Oral Health Care for People With Special Health Care Needs: A Call to Action

Articles inside

State of the CDA Foundation

Oral Health Care for People With Special Health Care Needs: A Call to Action

Oral Health Care For Californians With Special Health Care Needs: A Chronic Problem in Need of a Solution

Predoctoral Curriculum Modifications in Caring for Patients With Special Health Care Needs

Medical-Dental Integration: A Promising Approach To Address Unmet Dental Needs of Children and Youth With Special Health Care Needs

Strategies To Reduce the Use of General Anesthesia for Children and Adolescents With Special Health Care Needs: Dental Desensitization and 'Shorten the Line' Models

C.E. Credit Worksheet

NYU Dentistry Oral Health Center for People With Disabilities

Care Coordination: A Valuable Adjunct To Dental Practice - Lessons Learned in a Public Health Setting

Billing for Extra Time Needed to Treat Individuals with Special Needs

RM Matters: Patient Dismissals: Why, When and How

Regulatory Compliance: OCR Cybersecurity Newsletter: Securing Your Legacy (System Security)

Tech Trends: A look into the latest dental and general technology on the market