Are We Really Training Dentists to Treat Patients with Special Needs?
Author: Timothy B. Followell, DMD, MS
Institutions: The Ohio State University, Nationwide Children’s Hospital.
Abstract
Individuals with special needs are often at higher risk for dental caries, yet
dental students are often not required to show competence in treating
patients with special needs. The Ohio State University requires its dental
students to rotate through a program in which they perform clinical
treatment for individuals who have intellectual or developmental disabilities.
In addition, the College of Dentistry has created a novel competency
examination that assesses the students’ ability to evaluate an individual with
special needs and to plan appropriate treatment. The students who have
challenged this pilot examination have passed at a high rate. Future plans
include implementing this competency examination program-wide.
Introduction
Dental services are the largest unmet
health care need for individuals with
special needs.1 Casamassimo et al.
found that only 10% of dentists frequently
treat children with special needs, and
only 25% of dentists recall having clinical
experience treating patients with special
needs in dental school.2 In order to
ensure quality dental education and
healthcare in the United States, the Commission on Dental Accreditation
(CODA) publishes standards that every accredited dental program must
follow.3 These standards are written to protect the public and to improve
the quality of oral health care. Dental and dental-related training
programs are very intensive, and educators must make difficult choices in
order to prioritize the most import components of didactic and clinical
curricula. CODA defines patients with special needs as, “Those patients
whose medical, physical, psychological, cognitive or social situations
make it necessary to consider a wide range of assessment and care
options in order to provide dental treatment. These individuals include, but
are not limited to, people with developmental disabilities, cognitive
impairment, complex medical problems, significant physical limitations,
and the vulnerable elderly.” Unfortunately, due to the competing
constraints placed upon the educational programs, CODA does not have
a standard that requires dental students to be competent in treating
individuals with special needs. Rather, CODA requires, “Graduates must
be competent in assessing the treatment needs of patients with
special needs.”
Methodology
Results
The purpose and intent of the Nisonger Center Dental Program Competency
Exam is to evaluate the dental student’s assessment of medical issues,
limitations impacting treatment, and obtaining informed consent. It is critical
for the dental student to assess the correct guardianship situation of each
patient and to obtain appropriate informed consent and informed assent,
when applicable. The dental student must understand the patient’s medical
history, and understand any impact the patient’s health has on treatment
considerations. In addition, the dental student needs to understand and
address any physical limitations the patient may have to receiving dental
treatment.
The Competency Exam is a pass/fail exam that is still in the pilot stage.
Currently, the exam is being administered by only one faculty member
(Followell) to dental students on the Nisonger rotation. Each student spends
approximately four clinic sessions at the Nisonger Center, and a student is
eligible to challenge the competency on the third or fourth clinic session, after
they have spent some time providing clinical treatment to individuals with
special needs. If a student fails the exam, s/he is allowed to repeat the exam
at the instructor’s discretion until the student exhibits satisfactory
performance. Because the competency examination is still considered to be
in the pilot phase, students were encouraged to complete the exam, but they
were not penalized if they were unable to challenge the competency.
Special Needs Patient
Assessment of Medical Issues, Limitations Impacting Treatment and
Obtaining Informed Consent
Student Name
Patient ID #
Course
Since the implementation of the pilot exam, there have been 156 dental
students who have rotated through the Nisonger Center Dental Clinic. Of
these students, 101 were eligible to challenge the competency exam. Of
the students that were eligible to challenge the competency, 50 students
completed the examination. Of these 50 students, there was one failure of
the examination. The reason cited for failure was lack of understanding of
the neurodevelopmental diagnosis. The student who failed the exam was
able to remediate the exam that same day. Fifty one students who were
eligible did not challenge the competency. Although the reason for not
challenging the exam was not recorded, the most common reasons for not
doing so were student absence, faculty absence, and patient
cancellation/broken appointment.
Discussion
This competency examination is aimed
at fulfilling the CODA standards, but The
Ohio State University has exceeded
these standards by requiring each
student to spend at least 32 hours in a
clinic treating patients with special
needs. The 98% pass rate among
students who challenged the
competency exam is hopefully an
indicator that graduates of the program
are well-prepared to treat individuals who
have special needs.
ELEMENTS AND INTENT OF COMPETENCY ITEMS
Number
Dent 4
Dent 7708
Type of Exam
Clinical Patient
I. INFORMED CONSENT
Students take this competency as part of their Nisonger rotation. Student may challenge this competency
beginning on their 3rd clinic session at Nisonger. Students should inform their instructor prior to the
beginning of the appointment that they are going to attempt the competency exam.
a. Student has identified correct guardianship situation* The student inquires about guardianship, notes whether
patient is their own guardian and identifies whether legal guardian is present
Specific criteria for each item is listed on the reverse side of this form.
b. Student has identified appropriate guardianship documentation – Student physically assesses and reviews
documentation denoting guardianship
Category
Item
c. Student has discussed procedures and gained appropriate*
Informed
Consent
Student has identified correct guardianship situation
Critical
Error
Student has identified appropriate guardianship
documentation
Student has discussed procedures and gained appropriate
Informed Consent
Student has discussed procedures and gained appropriate
Informed Assent
Systems
Student has completed medical history review and
Review
presented findings to attending
Student has identified and followed-up on any outstanding
medical consultations
Student understands salient features of medical diagnoses
and proposed dental treatment
Student understands salient features of
intellectual/developmental
diagnosis and proposed dental treatment
Patient
Student has identified and addressed any physical
Assessment limitations to patient movement during care
Student has discussed with faculty and guardian and patient
care plan
Pass
Fail
Not
Applicable
*
*
*
Informed Consent- Student explains risks/benefits/alternatives to treatment to guardian,
answers all questions, and has been given consent to proceed with treatment
ii.
Informed Assent- In applicable clinical situations where patient is 12 or older, student explains
treatment in language commensurate with developmental age, and has to the best of patients ability to
render so, gained assent.
*
II. SYSTEMS REVIEW
a. Student has completed medical history review and presented findings to attending*- Medical History
reviewed and all positive findings have been explained and addressed with guardian/patient
b. Student has identified and followed-up on any outstanding medical consultations- Any outstanding consults
are identified by student and appropriate questions for physician presented to dental attending.
c. Student understands salient features of medical diagnoses and proposed dental treatment- Student has
looked up medical diagnoses and demonstrates understanding at potential dental treatment implications.
*
If a student does not “pass” an applicable critical error item, they will fail the competency exam. In addition,
students must “pass” at least 2 of the remaining 5 items in order to pass the competency exam.
YES
d. Student understands salient features of intellectual/developmental diagnosis and proposed dental
treatment- Student presents to attending potential behavior management techniques that might be most effective,
INCLUDING discussing ‘best’ way to manage behavior with guardian/caregiver/parent.
III. PATIENT ASSESSMENT
This form should be given to the clinic site office manager whether or the not student has passed the
competency.
The above named student has passed this competency exam
i.
NO
a. Student has identified and addressed any physical limitations to patient movement during care *- Student
presents need for modified patient positioning and/or operator position during treatment
Conclusion and Future Directions
Many of the students were logistically unable to challenge the competency
due to scheduling issues such as missed clinic sessions or attending crosscoverage. In the future, we anticipate expanding the competency to
include additional attendings, both at the primary Nisonger Center Dental
Clinic, and in the program’s satellite clinic. Although this competency exam
assesses only the student’s ability to assess a patient and not to actually
provide treatment, we anticipate that graduates of this program will be more
likely to treat patients with special needs upon completion of this rotation.
b. Student has discussed with faculty and guardian and patient care plan – Student discusses treatment plan
with appropriate guardian/patient/attending combination
Faculty name
Faculty signature
References
Date
CONTINUED ON REVERSE
1.
Figure A. Competency Examination Form, Front and Back
2.
3.
Newacheck PW, McManus M, Fox HB, Hung Y-Y, Halfon N. Access to health care for children with special health care needs. Pediatrics
2000;105:76-766.
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;68:23-8.
Accreditation Standards for Dental Education Programs. Commission on Dental Accreditation.