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

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.

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.

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The 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 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 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 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.

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

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 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 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.

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

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

Experiences that touch the heart change the mind in indelible ways. 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 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, 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.

REFERENCES

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 PRECEDE- PROCEED 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.

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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.

THE CORRESPONDING AUTHOR, Allen Wong, DDS, EdD, can be reached at awong@pacific.edu.